back to talk about a little more electrocardiography and in this segment we're gonna talk about hype okay Cory is waiting in the wings to talk about hyper K we're gonna talk about over the next five minutes a very very simple EKG finding which when you see it is enormous ly predictive of severe hypochondria point v 2.0 or even under 2.0 so this is severe hypokalemia at you waves this is a no brainer this is on your boards nobody would miss this you've got a very nice T wave followed by a pretty nice generous you if these are real ye waves when I see you waves that are as big as the T wave or even bigger than the T wave to me that's a real you wave alright not the tiny of blips that people make a fuss about but when the T wave is getting big these are often times referred to as camel humps Marriot used to call these camel humps the computer thinks this is just a big t wave so it produces a prolonged QT in reality the purists would say it's not a pro long QT it's actually t you fusion I say get a life to call it a pro long QT alright so now think about this for just a moment before we move forward into the slides as your potassium gets higher T waves get big everyone knows that as your potassium Falls this lecture as your potassium Falls your T waves get smaller and smaller and the U wave grows eventually the T wave goes flat and you just have a big U wave producing what really looks like a prolonged QT as the potassium Falls even more that T wave sinks even further producing ST segment sagging and an inverted T wave which then bounces up into a big upright u wave and this is pride that predominantly in the precordial leads V 2 V 3 those are kind of your money leads but when you see this pattern of the T wave going down and then catapulting north's that's a very predictive finding that tells you that you're looking at severe hypokalemia so times people call this a reverse wells wave it's like the opposite of the Welland's wave which predicts Proxima LED don't make the mistake of calling this a Whelan's wave I refer to this as the Nickell acam T wave and I'll tell you why in just a second for those that don't know so again severe hypokalemia at T wave and this is the you wave so you've got this reverse while ensure the biphasic type of T wave now just to review this is a Whelan's wave notice that Whelan's biphasic T waves go up and then down the severe hypokalemia stakin leak all this Whelan's is not well as well as goes up and down this goes down and then up I refer to this as the Nicola cam T wave and the reason I do is people started saying this is the reverse Wells wave and I said well it's already has his name on something the winter it's got his name on a T wave I want to name something also I'm not gonna name after myself - this kind of arrogant I thought you know what my kids were standing next to me I was looking through this and they said it kind of looks like a roller coaster roller coaster T waves that's hypokalemia and I thought you know what I'm just damn it I'm gonna name it after my kids so there's Nikhil on the Left Alena in the middle and Cameron on the right so this is now referred to as the Nicola cam T wave and if you google search the Kell cam we've made it so I call them them - Kelly Kim T waves anyway so again you're looking at an inverted T wave that's the T wave catapulting up above the baseline that's eua when you see this is enormous ly predictive of severe hypokalemia you can look at this 12-lead ECG and V 2 V 3 you see this pattern you snap your fingers and say it's hypokalemia and an hour before the labs come back you already know the diagnosis now what I always tell people don't tell your staff that you know about this all right what you should do is when you see this EKG just you know bring everybody into the room listen to the patient's heart with your stethoscope and say is hypokalemia and people will people are like wow how did you know this you this is great for the interns there since our all into ultrasound you know show me how you diagnose hype okay an ultrasound right you can't do it so if you really want to play with their minds take the ultrasound probe and look at the heart say it's hype okay right so by second or third year they kind of they've learned about this I can't play with them but the interns I I can get them so again take a look at v2 and v3 there is your NIC Kelly cam t wave goes down and then up very predictive of severe hypokalemia another example in this case is primarily just v3 the computer is gonna read this as a prolonged QT it's actually inverted t fused to a you wave I still consider it in my differential for prolonged QT because these patients are still at risk for ventricular arrhythmias so I'm gonna worry about this there's another nice example take a look at their at lead v2 and in v3 just like so looks like a really long QT interval there's another one this is profound you look at this and you can again just an hour before the lab calls you back and says is hemolyzed probably you're gonna know that this patient has severe hypokalemia will at least start the magnesium on these patients and there's another nice example so it's a very very predictive pattern which can tell you long before the lab calls that your patients got severe hypokalemia and yet another example v2 and v3 are your money leads don't confuse this with the schema or Whelan's this is the opposite of the well and so again when you see this T wave that goes down and then catapults North's the big you wave that is hypokalemia and again it's a very nice and predictive pattern alright let's hear about hyperkalemia things [Applause] [Music]