Nightmare EKG!!!

I know I know……your probably hoping you NEVER see this EKG, but what if you do? What is this???  How would you treat it?  Would it make a difference if the patient was stable or unstable?

The above EKG represents atrial fibrillation with WPP (Wolf-Parkinson-White syndrome).  It is beyond the scope of this blog entry to discuss the pathophysiology of WPW,but I’ve attached a link to a great review on the new epocrates online site.  If you get a chance, spend some time on the site, its nicely done! The main thing I wanted to review is treatment of this condition IF you should happen to get a patient with this EKG.

First, in order to diagnose this EKG, note that it is a wide complex, irregularly irregular tachycardia.  The differential for this is relatively small (afib with bundle branch block, polymorphic vtach, torsades, and afib with WPW). There are a couple hints that the EKG you’re looking at is afib with WPW.  Most of the time the rate will be over 250 and you will have VERY ODD looking QRS complexes.  I think most physicians can easily distinguish between torsades and the EKG above.  The hard decision is distinguishing between afib with WPW and afib with bundle branch block.  Here’s my recommendation: if a patient comes in with this EKG, do something to get them out of this rhythm as soon as possible!  Afib with WPW is extremely unstable!  Don’t spend time trying to find out which it is.

The other thing to remember is not to treat these patients like usual afib.  If you treat with beta blockers and calcium channel blockers, you’ll block their AV node and the accessory pathway will take over……..and your patient will DIE!

Most people recommend one of two treatment options:

1. Cardioversion

2. Procainamide

If I see a patient tonight with this EKG, I’m voting electricity!  What about the rest of you?

Link to epocrates article


2 thoughts on “Nightmare EKG!!!

  1. Disclaimer: This is my opinion only.

    Anything seemingly stable will maybe be that way transiently because the person is young. This is an UNSTABLE RHYTHM –>

    If that young person were your son or daughter, wouldn’t you want him or her cardioverted by their friendly neighborhood emergency physician?

    At Ohio State –> DCCV / someone else call EP / follow recs / admit stabilized patient to Heart1 or HRE

  2. atrial fibrilation in WPW.
    treat:cardiovertion if unstable,you may try procainamide or amiodarone if stable

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