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HPI: Patient is a 54-year-old male presenting with palpitations and near syncope. Patient states that he was told he had a “heart problem” as a child. He was diagnosed with atrial fibrillation some 10+ years ago.
 
EKG:

EKG Interperitation:
Rate estimated to be in the high 100s and irregularly irregular. QRS is wide. There are no appreciable P waves. Does not fit any typical bundle branch pattern.
 
Discussion:
Is this V tach? No. The patient has a wide complex irregulary irregular waveform. This is MOST likely to be a patient with WPW and a-fib. This is easily confused with ventricular tachycardia. How to differentiate:
·      Irregularly irregular
·      Rapid
·      Wide complex
·      Does not fit bundle branch pattern
·      No P waves
 
Treatment:
·      DO NOT give: adenosine, verapamil, diltiazem, digoxin, beta blocker or amio
        o   Due to the presence of accessory pathway blocking down the AV node, may cause the accessory pathway to become the primary driver of conduction.
·      Treated with IV procainamide if clinically stable.  Dose is 15-16 mg/kg given at a rate no faster than 50 mg/min.
·      If unstable: Immediate DC cardoversion
·      Patients will require admission with likely EP study.

By Dr Andrew Puchiaty