Hey guys,
Check out this case and let me know what you think. I will post the answer and discussion in 1-2 weeks.
45 year old male with history of abnormal heart beat, htn complaining of difficulty breathing and palpitations. His vital signs are 130/90, HR 215. The pt is awake, alert and conversing. Diaphoretic, anxious with nml breath sounds. His ECG is shown below:
Identify the rhythm:
What is your next step in management:
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jwillis
Program Director of SUNY Downstate EM Residency
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8 Comments
doty · March 23, 2012 at 6:46 pm
Nice EKG. I have a lot to say about this. Excited to see the thoughts. Doty
admin · March 27, 2012 at 8:11 am
Hey guys- I’m thinking WPW w afib vs vtach. Leaning a little more toward WPW afib because of variable qrs duration, delta wave, and irregularity. If wpw afib, i’d avoid avnodal blockers and reach for the amio if stable, cardiovert if unstable. Rodrigo
Mark Silverberg · March 28, 2012 at 12:34 am
I totally agree with rodrigo. However I am not a big amio fan. I think I would go with the procainqmide instead. I believe both are acceptable according to the AHA though.
benny · March 29, 2012 at 5:18 pm
i agree with kong about the rhythm (WPW with a fib) and with silverfish about procain…amio seems to be falling out of favor. this would scare the poop outta me, BTW
doty · March 29, 2012 at 6:47 pm
I think WPW with aberrancy is a good thought. Is it important to be able to make that diagnosis? Doe’s it matter? What do you do if you are’t sure?
I am not sure Amio is a good drug for this. The AHA recommendations are wrought with issues when it comes to Amio. It may actually be harmful, but that is all theoretical. There are better drugs that do not have real or even potential downsides.
The AHA has been known to increase the level of recommendations based on Pharma money. True.
jwillis · April 5, 2012 at 12:41 am
So the rhythm is WPW with AFib. Good job Dr. Kong
In AF with WPW the normal rate-limiting effects of the atrioventricular node are bypassed, and the resultant excessive ventricular rates (sometimes 200 to 240 beats/min) may lead to ventricular fibrillation and sudden death. The treatment of choice is direct-current cardioversion. The usual rate-slowing drugs used in AF are not effective, and digoxin and the nondihydropyridine Ca channel blockers (eg, verapamil, diltiazem) are contraindicated because they may increase the ventricular rate and cause ventricular fibrillation. If cardioversion is impossible, drugs that prolong the refractory period of the accessory connection should be used. IV procainamide is preferred, but any class Ia, class Ic, or class III antiarrhythmic can be used.
Let me know what you guys think.
Ian deSouza · April 5, 2012 at 1:15 am
Yeah, with such a high HR, sedate and DCCV! It would take a whole lot of patience to wait on procainamide in this case….
doty · April 5, 2012 at 11:23 am
Just to spill the beans on my last post. One can treat all wide-complex tachycardias (WCT) the same. I think it is easy to over-think this and get into real trouble by thinking a lot about the difference between V-tach and a accessory pathway with aberrancy. It isn’t really important as you can always treat WCTs like V-Tach. Procaine is a great drug and if the patient is stable is a reasonable choice. Only certain types of WPW and re-entrant tachycardias will have this increase in pulse with nodal-blocking agents (read about orthodromic vs antidromic conduction), so nodal blocking agents won’t always hurt the patient but they might. Therefore, stay away from these meds altogether.
However, deSouza brings up a good point (as usual), and if the patient doesn’t look well (dyspnea and diaphoresis as above), electricity is fast and effective.