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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