Early electrocardiogram manifestations of hypokalemia

Written by Gan Jun
Endocrinology
Updated on March 28, 2025
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When hypokalemia occurs in the human body, it produces characteristic manifestations on the electrocardiogram (ECG) known as U waves. These so-called U waves appear as small waves at the tail end of the ST-T segment, often accompanied by a slight depression of the ST-T segment and mild changes in the T wave. If hypokalemia is severe, it can induce supraventricular arrhythmias, including premature ventricular contractions or first-degree atrioventricular block. In very severe cases, it may lead to life-threatening torsades de pointes, a type of ventricular tachycardia. Therefore, monitoring blood potassium levels and timely potassium supplementation are crucial for these patients to protect their health and safety.

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Written by Wei Shi Liang
Intensive Care Unit
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Causes of hypokalemia

Potassium is one of the essential electrolytes necessary for life. Its physiological functions mainly include maintaining cellular metabolism, regulating osmotic pressure and acid-base balance, and preserving cell stress response, etc. Daily potassium intake is about 100 millimoles, with 90% excreted through the kidneys and the remainder through the gastrointestinal tract. Common causes of hypokalemia include reduced intake, such as long-term inability to eat without timely potassium supplementation. Even though potassium intake decreases, the kidneys continue to excrete potassium, leading to potassium loss. The second cause is increased excretion, which includes losses through the gastrointestinal tract and the kidneys, both of which can lead to hypokalemia. The third cause is the movement of potassium from outside to inside the cells, which can occur during metabolic alkalosis or when glucose and insulin are administered, promoting the transfer of potassium ions into the cells, resulting in hypokalemia.

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Written by Gan Jun
Endocrinology
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Early electrocardiogram manifestations of hypokalemia

When hypokalemia occurs in the human body, it produces characteristic manifestations on the electrocardiogram (ECG) known as U waves. These so-called U waves appear as small waves at the tail end of the ST-T segment, often accompanied by a slight depression of the ST-T segment and mild changes in the T wave. If hypokalemia is severe, it can induce supraventricular arrhythmias, including premature ventricular contractions or first-degree atrioventricular block. In very severe cases, it may lead to life-threatening torsades de pointes, a type of ventricular tachycardia. Therefore, monitoring blood potassium levels and timely potassium supplementation are crucial for these patients to protect their health and safety.

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Written by Wang Li Bing
Intensive Care Medicine Department
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How to supplement potassium for hypokalemia

Hypokalemia generally has two common methods of potassium supplementation. The first is oral potassium supplementation, and the second is intravenous potassium supplementation. Oral potassium supplementation is the safest method, for example, taking potassium chloride sustained-release tablets orally, as well as potassium chloride injection solution orally, and eating more potassium-rich vegetables and fruits. The second method is intravenous potassium supplementation. For intravenous potassium supplementation, it is important to pay attention to the patient's urine output. If the patient's urine output is adequate, intravenous potassium supplementation can be appropriately performed, and the concentration of intravenous potassium supplementation should not exceed 0.3% to prevent arrhythmias caused by hyperkalemia. (Please use medications under the guidance of a doctor.)

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Written by Gan Jun
Endocrinology
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Patients with hypokalemia can have what kind of urine?

When patients have hypokalemia, they often exhibit paradoxical aciduria, which is a typical manifestation of hypokalemia. In hyperkalemia, however, there is paradoxical alkaline urine. When serum potassium ions decrease, the renal tubular epithelium reduces its potassium excretion function and instead increases hydrogen excretion, leading to increased reabsorption of sodium and bicarbonate. This results in metabolic alkalosis, causing an increase in plasma bicarbonate, unlike typical alkalosis where alkaline urine is excreted. However, in the case of hypokalemia, acidic urine is excreted, hence it is called paradoxical aciduria.

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Written by Gan Jun
Endocrinology
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What are the clinical manifestations of hypokalemia?

When patients present with hypokalemia, the first symptoms often include significant muscle weakness and episodic flaccid paralysis. Additionally, there may be a decrease in the stress tolerance of cardiac myocytes, leading to arrhythmias or an increased heart rate. Hypokalemia can also cause damage to the renal tubules, leading to a decline in kidney excretion functions. The most crucial manifestation is endocrine disorder, which can lead to kidney failure. The primary treatment for hypokalemia is potassium supplementation. For mild hypokalemia, it is advisable to consume foods high in potassium, such as oranges, bananas, and other fruits and vegetables. In cases of severe hypokalemia, potassium can be administered intravenously or orally, and blood potassium levels should be dynamically monitored.