ECG: Prolong PR interval with Generalized Up sloping ST Depression in Hypokalaemia Patient.

This is the ECG of 23 years old lady, post partum D24 who presented with generalized body weakness for 3/52 duration and unable to ambulate for 2/7 duration. Otherwise, no diarrhea or vomiting, no fever, no PV bleeding or foul smelling discharge.

She also has similar presentation during her last post partum but did not seek medical attention and claim that the problem resolves spontaneously.

On examination, patient is conscious and alert, hydration and perfusion status is good, CRT less than 2 second, good pulse volume. Examination of heart, lung and abdomen are normal. Neurological assessment revealed generalized body weakness with power of 2/5, hypotonic, hyporeflexia and intact sensation. Patient also have weakness of the right Sternocledomastoid and trapezius muscle weakness ?Accessory nerve involvement.

ECG shows sinus rhythm with prolong PR interval and generalized up sloping ST depression.

His potassium level is 1.6 mmol/l with other electrolytes are normal. VBG shows metabolic acidosis and random blood sugar is 5.5.

Paralytic Ileus Secondary to Severe Hypokalaemia in 11 months old baby

11 months old, baby boy, non Malaysian, not immunized, home delivery, early weaning and non fully breast fed presented with 1/52 history of abdominal pain preceded by AGE symptoms for 1/52 prior to the onset of abdominal distension. Currently, parent also complaints that the baby develops vomiting for the past 2 days, poor feeding and less active. Otherwise, no fever, no irritable cry and discoloration of sclera.

On admission, patient was still conscious and alert, moderately dehydrated but pulse volume still good and capillary refilling time not prolonged. He was mildly tachypnoeic and tachycardic, afebrile and normoglycaemic. Blood pressure was 99/63 and SPO2 100% under room air. Examination of cardiovascular and respiratory system was uneventful. Per abdomen, it was distended but soft, non tender, no mass palpable, tympanic on percussion and no ascites. On auscultation, bowel sound was absent. Per rectal examination shows yellowish soft stool and no blood or mucous seen. 

Initial VBG shows mild metabolic acidosis with Ph 7.303, PCO2 37.7, HCO3 18.3, BE -7.4.

FBC result was as follow Hb 10.3, PCV 35, TWBC 20.1 (predominant neutrophils) and platelet 587. BUSE results were as follow Na: 140, K+ 1.5, urea 1.1, Cl- 106 and creat 35. Corrected Ca2t 2.14, Po42- 0.78 and Mg2+ 1.02

The abdominal x ray shows grossly dilated small and large bowel. The bowel wall is not thickened and no free fluid noted. Chest X Ray shows no gas under diaphragm and minimal right perihilar haziness.

We were unable to do the ECG as we don’t have a pediatric electrode size but the cardiac monitoring showed flattening of T Wave.

A Diagnosis of paralytic ileus secondary to severe hypokalaemia with underlying acute gastroenteritis and some dehydration was made and he was also covered for bronchopneumonia.

This patient was kept nil by mouth, Ryle's tube inserted with free flow and four hourly aspiration, and was put under continuous cardiac monitoring. Fast correction of potassium was done in view of very severe hypokalaemia. In view of prolong duration of AGE and paralytic ileus; he was also being covered for gastrointestinal infection/ septic ileus. Therefore he was started on IV cefuroxime and Metronidazole.

After two days of treatment, the potassium normalizes to 4.2 and patient shows marked improvement. The bowel function gradually return and patient was allowed orally and then discharged after 4 days of hospitalization.