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Extreme Bradycardia with Variable Block in Severe Hyperkalemia: A Forgotten Culprit in Brady-arrhythmia

Bradycardia is commonly encountered in emergency department. Hyperkalemia may sometime cause bradycardia with block and also synergize with AV node blockers to cause bradycardia and hypoperfusion. We report a 53 years old male with history of hypertension, congestive heart failure and coronary artery disease was admitted to hospital for sudden onset of breathlessness. He underwent Percutaneous Coronary Intervention (PCI) to Left Anterior Descending (LAD) artery and Left Circumflex (LCx) artery one year ago and taking Aspilet 80 mg for daily, Clopidogrel 75 mg daily, Ramipril 5 mg daily, Atorvastatin 20 mg daily, Metoprolol 25 mg daily, Spironolactone 25 mg daily and Frusemide 40 mg daily. Significant physical examination was remarkable for a temperature 97.5’F, blood pressure of 110/70 mmHg, heart rate of 40 beats per minute, oxygen saturation was 99% on air and both lung were full with audible crepitation by auscultation. He was given atropine 0.6 mg bolus and transcutanaeous pacing with unimproved heart rate and then a transvenous pacing was immediately placed before the blood investigation results were returned. His relevant laboratory values were significant for a potassium of 7.99 mmol/L(ref range: 3.5-5.2 mmo/l), creatinine of 458 micmol/L (ref range: 59-104 micmol/L), Urea of 33.9 mmol/L (ref range: 2.7-8.0 mmol/l), random blood glucose of 233mg/dl, sodium 126.8 mmol/L (ref range 135-145 mmol/L), anion gap of 13.5 mmol/? (ref range: 3.6-11.0 mmo/L) and bicarbonate of 15.6 mmil/L (ref range: 22-29 mmol/L). He was given calcium glucoronate, insulin with dextrose, kaexylate, nebulizer salbutamol with significant improvement in his potassium levels to 4.6 in 24 hours. In Cardiac intensive care unit his heart rate was improved and the transvenous pacemaker was turned off the next day.