Vomiting, hyperkalaemia and cardiac rhythm disturbances.

A 51-year-old man presented with profuse vomiting and epigastric discomfort. The patient was known to suffer from a bipolar affective disorder with previous hospitalization for psychotic depression and attempted suicide. An ECG tracing showed normal sinus rhythm, inverted T waves in leads II, III and AVF and depressed ST segments in V4–V6 (Figure 1). Laboratory investigations revealed a serum potassium of 6.4 mmol/l, urea 28 mg/dl and a CPK level of 313 IU/l (normal 15–195). An initial diagnosis of acute coronary insufficiency was made and the patient treated with isosorbide dinitrate spray to no effect. Hyperkalaemia was managed by the administration of a glucose/insulin infusion and Fig. 2. ECG tracing 4 h after admission, showing first degree AV oral sodium polystyrene sulphonate resin. Although block with intervals of AV dissociation. serum potassium level declined to 4.8 mmol/l, over the ensuing 24 h rhythm disturbances (as shown by the serial ECGs in Figures 2–4) developed culminating in refractory polymorphic ventricular tachycardia and the patient’s demise.