CMC COMPENDIUM
  • RESIDENCY
    • About CMC
    • Curriculum
    • Benefits
    • Explore Charlotte
    • Official Site
  • FELLOWSHIP
    • EMS
    • Global EM
    • Pediatric EM
    • Toxicology >
      • Tox Faculty
      • Tox Application
    • (All Others)
  • PEOPLE
    • Program Leadership
    • PGY-3
    • PGY-2
    • PGY-1
    • Alumni
  • STUDENTS/APPLICANTS
    • Medical Students at CMC
    • EM Acting Internship
    • Healthcare Disparities Externship
    • Resident Mentorship
  • #FOAMed
    • EM GuideWire
    • CMC Imaging Mastery
    • Pediatric EM Morsels
    • Blogs, etc. >
      • CMC ECG Masters
      • Core Concepts
      • Cardiology Blog
      • Dr. Patel's Coding Blog
      • Global Health Blog
      • Ortho Blog
      • Pediatric Emergency Medicine
      • Tox Blog
  • Chiefs Corner
    • Top 20
    • Current Chiefs
    • Schedules >
      • Conference/Flashpoint
      • Block Schedule
      • ED Shift Schedule
      • AEC Moonlighting
      • Journal Club/OBP/Audits Schedule
      • Simulation
    • Resources >
      • Fox Reference Library
      • FlashPoint
      • Airway Lecture
      • Student Resources
      • PGY - 1
      • PGY - 2
      • PGY - 3
      • Simulation Reading
      • Resident Wellness
      • Resident Research
      • Resume Builder
    • Individualized Interactive Instruction

Irregular Wide Complex Tachycardia: Vtach?

10/7/2015

0 Comments

 
​HPI: Teenage female with SOB, presyncope, and palpitations x 1 hour.  HR is 220 in triage. BP 118/84, RR 28, SpO2 96%. Alert and oriented.
 
EKG:
Picture
Question:  What arrhythmia is this? How you would treat this rhythm in a stable patient. What if the patient were unstable?
 
 
ECG Interpretation: Rate of 173/min.  Irregularly irregular rhythm, wide complex tachycardia with intermittent narrow complexes and changing of QRS morphologies. No LBBB or RBBB pattern.
 
Diagnosis: Afib with WPW
 
Let’s discuss the interpretation of irregularly irregular Wide Complex Tachycardias (WCT), and then we will discuss the treatment.
 
At first glance, it is difficult to assess the regularity, but with some scrutiny, you can see that the rhythm is irregular. The differential diagnosis of irregularly irregular WCT is essentially limited to three main dysrhythmias. Dr. Littmann calls these FBI: Fast, Broad, and Irregular:
  • Afib with LBBB
  • Afib with RBBB
  • Afib with WPW
Picture
​The above ECG is an irregularly irregular WCT meeting the criteria for LBBB as below (upgoing in I, deep S waves in V1). Note the rate of 134. Fast, but not extremely fast, indicating likely transmission through the AV node.
Picture
Picture
​Consider RBBB, looking for triphasic QRS, with rSR’ and 2nd upgoing phase wider and taller than first upgoing phase as shown in these images:
Picture
Picture
So we have scrutinized our irregularly irregular WCT and found no evidence of BBB pattern. We are now left with Afib with WPW. Why is this important? The treatment is completely different from regular WCT (usually Vtach) and Afib with BBB pattern.
 
Treatment of FBI, Fast Broad and Irregular:
  • Unstable
    • DC Cardioversion!
  • Stable
    • IV PROCAINAMIDE, 18-20 mg/kg at 20-30 mg/min (slow)
    • IV Ibutilide
    • Avoid all AV nodal blockers!
      • Adenosine
      • Verapamil
      • Diltiazem
      • Beta-blockers
      • Digoxin
      • Amiodarone (has both beta-blocker and Ca-channel blocker properties)
    • May consider DC Cardioversion if procainamide or ibutilide are unavailable
    • Some sources (e.g. 10-second EM app) suggest amiodarone for "polymorphic or irregular" WCT. Amiodarone was once the first-line treatment for irregular WCT, but there have been many poor outcomes associated with this. Treatment with amiodarone and other AV nodal blockers has resulted in patient decompensation including reports of death on multiple occasions.
Discussion:
  • Recall that WPW causes an accessory electrical pathway which allows impulses to bypass the AV node, resulting in tachydysrhythmias. Most commonly, this causes a reentrant tachycardia (70-80%), which is managed as any other SVT. Adenosine is appropriate in these patients as it blocks the reentrant rhythm and allows a normal sinus rhythm to resume. 10-30% of the time, though, atrial fibrillation occurs as we have discussed. In Afib, rates can be >200 bpm, which is rarely seen in the absence of accessory pathways (recall max sinus heart rate estimation using 220 minus age). Any tachydysrhythmia with rate > 200 should raise suspicion for an accessory pathway. Constantly changing QRS morphology should also lead you to consider WPW with Afib.
  • If the AV node is blocked in a patient with WPW who is in Afib, Vfib or asystole can and have occurred, unfortunately at times in young, healthy patients.
 
Key Points:
  • Consider WPW with Afib in any Fast, Broad, Irregular (FBI) rhythm without signs of BBB pattern, especially if rate is excessive (>180)
  • Treatment of stable WPW with Afib is procainamide or ibutilide. Don’t block the AV node! Cardiovert if unstable.
  • In a patient with known WPW with a regular narrow complex rhythm (SVT), standard SVT treatment is appropriate
 
As a reminder for recognizing WPW in the non-tachycardic patient’s ECG:
Picture
Picture
References:
  • Amal Mattu’s video lecture on Afib with WPW: https://www.youtube.com/watch?v=3Opx1XMA-yo
  • Dr. Littmann’s ECG lectures
  • FOAMCAST.org Episode 15 on Afib/Flutter: http://foamcast.org/2014/09/21/episode-15-atrial-fibrillationflutter/
  • Boriani, Giuseppe et al. 'Ventricular Fibrillation After Intravenous Amiodarone In Wolff-Parkinson-White Syndrome With Atrial Fibrillation'. American Heart Journal 131.6 (1996): 1214-1216. Web.
  • Marius A. Tijunelis and Mel E. Herbert (2005). Myth: Intravenous amiodarone is safe in patients with atrial fibrillation and Wolff–Parkinson–White syndrome in the emergency department. CJEM, 7, pp 262-265. doi:10.1017/S148180350001441X.
 
By:  Dean Tanner, PGY1 EM
0 Comments

Awooooooooo

6/1/2015

0 Comments

 
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:
Picture
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
0 Comments

    EKG Challenge

    Picture

    Author

    ER residents on Dr. Littmann's cardiology service present an interesting EKG and core concepts from Dr. Littmann.

    Subscribe to Blog
    Littmann's EKG Pearls
    Videos Of Littmann's Lectures

    Archives

    January 2016
    November 2015
    October 2015
    September 2015
    August 2015
    July 2015
    June 2015
    May 2015
    April 2015

    Categories

    All
    Afib
    AIVR
    Aortic Stenosis
    Atrial Flutter
    AVR Sign
    Bifascicular Block
    Cardiac Tamponade
    CHF
    Dextrocardia
    HCOM
    High Lateral MI
    Hyperkalemia
    LAFB
    Paced Rhythms
    Pulmonary Hypertension
    PVC
    Respiratory Distress
    Short QT
    South African Flag Sign
    STEMI
    WPW

    Disclaimer: All EKG's and images are the sole property of CMC Emergency Medicine Residency and cannot be reproduced without written consent.  Patient identifiers have been redacted/changed or patient consent has been obtained.  Information contained in this blog is the opinion of the authors and application of material contained in this blog is at the discretion of the practitioner to verify for accuracy.

    RSS Feed

Powered by Create your own unique website with customizable templates.
  • RESIDENCY
    • About CMC
    • Curriculum
    • Benefits
    • Explore Charlotte
    • Official Site
  • FELLOWSHIP
    • EMS
    • Global EM
    • Pediatric EM
    • Toxicology >
      • Tox Faculty
      • Tox Application
    • (All Others)
  • PEOPLE
    • Program Leadership
    • PGY-3
    • PGY-2
    • PGY-1
    • Alumni
  • STUDENTS/APPLICANTS
    • Medical Students at CMC
    • EM Acting Internship
    • Healthcare Disparities Externship
    • Resident Mentorship
  • #FOAMed
    • EM GuideWire
    • CMC Imaging Mastery
    • Pediatric EM Morsels
    • Blogs, etc. >
      • CMC ECG Masters
      • Core Concepts
      • Cardiology Blog
      • Dr. Patel's Coding Blog
      • Global Health Blog
      • Ortho Blog
      • Pediatric Emergency Medicine
      • Tox Blog
  • Chiefs Corner
    • Top 20
    • Current Chiefs
    • Schedules >
      • Conference/Flashpoint
      • Block Schedule
      • ED Shift Schedule
      • AEC Moonlighting
      • Journal Club/OBP/Audits Schedule
      • Simulation
    • Resources >
      • Fox Reference Library
      • FlashPoint
      • Airway Lecture
      • Student Resources
      • PGY - 1
      • PGY - 2
      • PGY - 3
      • Simulation Reading
      • Resident Wellness
      • Resident Research
      • Resume Builder
    • Individualized Interactive Instruction