31 yo M presents to your Emergency Department with palpitations and shortness of breath.
His EKG is below:
1. What is the interpretation?
Rate, rhythm, axis, intervals, etc….
2. What is the emergent and subsequent treatment?
Best answer by 8/21/15 at noon will be the winner!
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eabram
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2 Comments
Ben Kaufman · August 15, 2015 at 7:47 pm
Dx: Irregularly irregular wide complex tachycardia (polymorphic QRS)
AFib @ ~180, LAD, shortened PR, prolonged QRS 2/2 WPW
Rx: NO Adenosine, BBlock, Ca2+ Block (risk arrhythmia)
HD Stable – Procainamide, Cardiology (ablation)
HD Unstable – DC Cardioversion
Itamar · August 18, 2015 at 3:58 pm
I agree with Benny “the Creole speaking genius” Kaufman’s diagnosis: Afib secondary to WPW syndrome (accessory pathway). However, I would like to add my thought process as well as a couple of more details to the mix.
Rate: ~180 bpm
Rhythm: Irregularly Irregular.
Axis: ~ -60° (L axis deviation – Fixed).
Intervals: QRS: ~120ms
PR interval: ~40ms (though I wouldn’t trust this interval in an extreme tachycardia, let alone a polymorphic one).
Morphology: Wide complex, polymorphic. No evidence of LBBB pattern, ¿RBBB? (hard to tell, polymorphic).
Wide complex tachycardia (WCT) differential: VTACH (including polymorphic) or SVT with aberrancy (i.e: afib w/accessory pathway or BBB, AVRT with antidromic conduction).
In our case, the fact that the rhythm is irregularly irregular narrows down the differential to Afib with BBB or accessory pathway, since AVRT and VTACH are typically regular.
The rest is easy, since only Afib with an accessory pathway would have a polymorphic morphology in combination of a WCT and an irregularly irregular rhythm. Afib with a BBB should remain monomorphic (…I think…).
Though rapid Afib with a RBBB came to mind since there is a questionable R’ in V1 (I think…) the complexes do seem overtly polymorphic, and therefore that probably is not the case.
Lastly, the only little fact that points against Afib with WPW is the fact that the rate is <200bpm (albeit close).
For treatment, I have nothing to add to Ben's terse words:
~ Avoid AV node blockers.
~ Synchronized cardioversion or chemically converttion with Procainamide (Cardiovert if HD unstable, defibrillate if pulseless).
~ Long term Tx: Ablation.