How hypokalemia causes tachycardia; how it affects resting membrane potential.

Electrolytes
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The ratio of INTRAcellular to EXTRAcellular potassium is important for generation of action

potentials and is essential for normal functions of neurons, skeletal muscles and cardiac muscles.
This is why potassium levels in the blood are strictly regulated within a narrow range between 3.5
and 5mmol/L. As the normal daily dietary intake of potassium varies widely and can be as much as
100mmol a day, the body must keep blood potassium levels within the normal limits. This is
achieved by 2 mechanisms:

- Excretion of potassium through the kidneys and intestines

- Shifting of potassium from the extracellular fluid into the cells by the sodium/potassium pump.

The pump is mainly regulated by hormones such as insulin and catecholamines. Hypokalemia is
defined as a serum potassium concentration LOWER than 3.5 mmol/L. Hypokalemia may result from
INCREASED excretion, INadequate intake or shift of potassium from the extracellular fluid into the
cells. Most commonly, hypokalemia is caused by excessive loss of potassium in the urine, from the
GI tract, or skin. The cause is usually apparent by the patient’s history of predisposing diseases or
medication. Urine potassium levels are measured to differentiate between RENAL and NON-renal
causes. Symptoms may include muscle weakness, cramping, tremor, intestinal obstruction,
hypotension, respiratory depression and abnormal heart rhythms. As potassium levels DEcrease in
the EXTRAcellular space, the MAGNITUDE of the potassium gradient across the cell membrane is
INCREASED, causing hyperpolarization. This moves the membrane voltage FURTHER from the
threshold, and a GREATER than normal stimulus is required to generate an action potential. The
result is a REDUCED excitability or responsiveness of the neurons and muscles. In the heart,
however, HYPER-excitability is observed. This is because HYPER-polarization ENHANCES the
“FUNNY” currents in cardiac pacemaker cells, resulting in a FASTER phase 4 depolarization and
thus a FASTER heart rate. The effect is greatest in Purkinje fibers as these are more sensitive to
potassium levels, as compared to the SA node. Increased automaticity of Purkinje fibers may lead to
the development of one or more ECTOPIC pacemaker sites in the ventricles, causing ventricular
premature beats, tachycardia and fibrillation. Reduced extracellular potassium also inhibits the
activity of some potassium channels, and thus DELAYS ventricular repolarization. As hypokalemia
becomes more severe, especially in patients with other heart conditions, the inward current may
exceed the OUTward current, resulting in early afterdepolarization and consequently extra
heartbeats. Prolonged repolarization may also promote re-entrant arrhythmias. Early ECG changes
in hypokalemia are mainly due to delayed ventricular repolarization. These include flattening or
inversion of T wave, increasingly prominent U wave, ST-segment depression, and prolonged QU
interval. Hypokalemia-induced arrhythmias require immediate potassium replacement. Oral
administration is safer but may not be effective in severe cases. If potassium infusion is indicated,
continuous cardiac monitoring and hourly serum potassium determinations must be performed to
avoid HYPERkalemia complications.