EKGenie December 2017

Case:

Your patient is a 27 yo M with no past medical history presents with a chief complaint of intermittent palpitations for the last 10 days.

Vital signs: HR 87 BP 124/84 RR 14 O2 97%RA Temp 98.7

Exam: unremarkable

EKG1.jpg

+ Rate

80

+ Rhythm

Regular, wide complex, sinus

+ Intervals

PR: 100msec QRS: 120msec QTc: wnl

+ Pathology

This EKG is full of many outstanding nuggets of information. However, most importantly, there is a short PR interval, wide QRS, slurred R waves (aka delta waves) This EKG suggests there is an accessory pathway outside of the AV node that allows unfiltered electrical flow through the atria and ventricles. This is why the normal AV nodal pause, represented by the PR interval on an EKG, is dramatically shortened.

+ Diagnosis

Wolff-Parkinson White syndrome

WPW should always cross your mind when evaluating patients complaining of palpitations or syncope. This is especially true with younger patients, as in this case

+ Why is this important?

WPW should always cross your mind when evaluating patients complaining of palpitations or syncope. This is especially true with younger patients, as in this case

+ What should be your next step in mangement

As always, the treatment algorithm begins with the evaluation of “stable vs unstable.” Stable patients, like in this case, should be admitted for expedited cardiac evaluation and ablation. For unstable patients, the treatment of choice is cardioversion or procainamide 20-50mg/min or 100mg Q5min until controlled.

+ Additional resources

Amal Mattu covers the basics: http://www.mededmasters.com/wpw.html

Dr Smith’s ECG Blog: http://hqmeded-ecg.blogspot.com/2013/03/wide-complex-tachycardia.html

Amal Mattu again: https://www.youtube.com/watch?v=3Opx1XMA-yo