Hypokalaemia
Robert Buttner and Ed Burns ●
Jun 3, 2021
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Hypokalaemia is defined as a serum potassium
level of < 3.5 mmol/L. ECG changes generally
do not manifest until there is a moderate
degree of hypokalaemia (2.5-2.9 mmol/L). The
earliest ECG manifestation of hypokalaemia is a
decrease in T wave amplitude.
ECG features of hypokalaemia (K <
2.7 mmol/L)
Increased P wave amplitude
Prolongation of PR interval
Widespread ST depression and T
wave flattening/inversion
Prominent U waves (best seen in the
precordial leads V2-V3)
Apparent long QT interval due to
fusion of T and U waves (= long QU
interval)
With worsening hypokalaemia…
Frequent supraventricular and ventricular
ectopics
Supraventricular tachyarrhythmias: AF, atrial
flutter, atrial tachycardia
Potential to develop life-threatening
ventricular arrhythmias, e.g. VT, VF and
Torsades de Pointes
Hypokalaemia: T wave inversion and prominent U
waves
QU interval: The apparent pseudo-prolonged QT
interval is actually the QU interval with an absent T
wave
The push-pull effect
Hypokalaemia creates the illusion that the T
wave is “pushed down”, with resultant T-
wave flattening/inversion, ST depression,
and prominent U waves
In hyperkalaemia, the T wave is “pulled
upwards”, creating tall “tented” T waves,
and stretching the remainder of the ECG to
cause P wave flattening, PR prolongation,
and QRS widening
Pathophysiology
Potassium is vital for regulating the normal
electrical activity of the heart. Decreased
extracellular potassium causes myocardial
hyperexcitability with the potential to develop
re-entrant arrhythmias.
Degree of Potassium level
hypokalaemia (mmol/L)
Mild 3.0 – 3.4
Moderate 2.5 – 2.9
Severe ≤ 2.4
Classification of severity of hypokalaemia
Handy tips
Hypokalaemia is often associated with
hypomagnesaemia, which increases the risk
of malignant ventricular arrhythmias
Check both potassium and magnesium
levels in any patient with an arrhythmia
Replace potassium to ≥ 4.0 mmol/L and
magnesium to ≥ 1.0 mmol/L to stabilise the
myocardium and protect against
arrhythmias – this is standard practice in
most CCUs and ICUs
ECG Examples
Example 1
Hypokalaemia:
Widespread ST depression and T wave
inversion
Prominent U waves
Long QU interval
This patient had a serum K+ of 1.7
Example 2
Hypokalaemia
ST depression and T wave inversion best
noted in inferior leads
Prominent U waves
Long QU interval
The serum K+ was 1.9 mmol/L.
Example 3
Hypokalaemia causing Torsades de Pointes
Another ECG from the same patient
Note the atrial ectopic causing ‘R on T’ (or
is it ‘R on U’?) that initiates the paroxysm of
TdP
Related Topics
Hyperkalemia
Hypokalemia
Hypercalcemia
Hypocalcemia
Hypomagnesemia
Advanced Reading
Online
Wiesbauer F, Kühn P. ECG Mastery: Yellow
Belt online course – Become an ECG expert.
Medmastery
Wiesbauer F, Kühn P. ECG Blue Belt online
course: Learn to diagnose any rhythm
problem. Medmastery
Rawshani A. Clinical ECG Interpretation ECG
Waves
Smith SW. Dr Smith’s ECG blog.
Textbooks
Mattu A, Tabas JA, Brady WJ.
Electrocardiography in Emergency, Acute,
and Critical Care. 2e, 2019
Brady WJ, Lipinski MJ et al.
Electrocardiogram in Clinical Medicine. 1e,
2020
Straus DG, Schocken DD. Marriott’s
Practical Electrocardiography 13e, 2021
Hampton J. The ECG Made Practical 7e,
2019
Grauer K. ECG Pocket Brain (Expanded) 6e,
2014
Brady WJ, Truwit JD. Critical Decisions in
Emergency and Acute Care
Electrocardiography 1e, 2009
Surawicz B, Knilans T. Chou’s
Electrocardiography in Clinical Practice:
Adult and Pediatric 6e, 2008
Mattu A, Brady W. ECG’s for the Emergency
Physician Part I 1e, 2003 and Part II
Chan TC. ECG in Emergency Medicine and
Acute Care 1e, 2004
Smith SW. The ECG in Acute MI. 2002 [PDF]
LITFL Further Reading
ECG Library Basics – Waves, Intervals,
Segments and Clinical Interpretation
ECG A to Z by diagnosis – ECG
interpretation in clinical context
ECG Exigency and Cardiovascular Curveball
– ECG Clinical Cases
100 ECG Quiz – Self-assessment tool for
examination practice
ECG Reference SITES and BOOKS – the
best of the rest
ECG LIBRARY
Electrocardiogram
EKG Library
Robert Buttner
MBBS (UWA) CCPU (RCE, Biliary, DVT, E-
FAST, AAA) Adult/Paediatric Emergency
Medicine Advanced Trainee in Melbourne,
Australia. Special interests in diagnostic and
procedural ultrasound, medical education,
and ECG interpretation. Editor-in-chief of
the LITFL ECG Library. Twitter:
@rob_buttner
Ed Burns
Emergency Physician in Prehospital and
Retrieval Medicine in Sydney, Australia. He
has a passion for ECG interpretation and
medical education | ECG Library |
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