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Interesting Case Rounds Alyssa Reed R1 Emergency Medicine.

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Presentation on theme: "Interesting Case Rounds Alyssa Reed R1 Emergency Medicine."— Presentation transcript:

1 Interesting Case Rounds Alyssa Reed R1 Emergency Medicine

2 CASE #1 16F presenting with 2 syncopal episodes over the last two days PMHx: chiari malformation, chronic back pain Meds: Naprosyn Vitals at Triage: % 5.5 Q: What else would you like to know? Q: What is your approach to this patient?

3 Syncope DDx 1. Focal Hypoperfusion of CNS Structures SAH Hyperventilation 2. Systemic Hypoperfusion Resulting in CNS Dysfunction Outflow Obstruction - CHD - valve stenosis Reduced Cardiac Output - WPW - SVT - Tachycardias Bradycardias - Long QT syndrome - Aortic dissection - Cardiomyopathy Vasomotor 3. Other CNS Dysfunction Hypoglycemia Seizure Toxic

4 Findings O/E: AVSS, no significant findings - N S1S2, no murmurs, no extra sounds, no JVD, no pulse delays, pressure same both arms, normal neuro exam Labs: CBC, Lytes, Ca, Mg, PO4 normal CXR: no cardiomegaly ECG

5 Dx???

6 WPW Definition: a preexcitation of the ventricles through an accessory pathway- the Bundle of Kent- which provides an abnormal pathway of electical communication between the atria and the ventricles WPW Pattern: ECG abormalities WPW Syndrome: ECG abnormalities and associated arrhythmia AVRT (80%) Atrial Fibrillation (15-30%) Atrial Flutter (5%)

7 Prevalence WPW Pattern % in general population % among first-degree relatives of affected patients - in one large study it was 2x more prevalent in males WPW Syndrome - approx 1% with pattern have arrhythmia - review of showed.25% had pattern but only 1.8% of these had a documented arrhythmia - sudden death: 0-.39% annually

8 CASE #2 8F presenting with several episodes of black-outs that she remembers dating back to when she was two. None witnessed. PMHx: healthy, no meds FHx: mom has some unknown heart condition- she was treated with something that ends in lol O/E: no significant findings Q: would you do an ECG?


10 Familial WPW WPW syndrome- 3.4% have 1st degree relative with preexcitation syndrome - much lower than I expected Usually inherited as autosomal dominant trait Can also be associated with a familial hypertrophic cardiomyopathy

11 Pathophysiology/EC G Bundle of Kent is a muscle fiber accessory pathway that directly connects the atria and the ventricles conduction down this pathway is faster allowing ventricular activation earlier but occurs at a slower speed Q: What are the basic ECG findings in sinus WPW? 1. PR is short 2. Delta wave 3. Wide QRS

12 1. Short PR due to rapid conduction through the accessory pathway and bypass of the AV node 2. Delta Wave upstroke slurred because of slow muscle fiber-to-muscle fiber conduction 3. Wide QRS fusion between early ventricular activation and the normal activation through the normal pathway

13 **the more rapid the conduction along the accessory pathway, the greater the amount of myocardium depolarized via the accessory pathway, resulting in a more prominent or wider delta wave, and longer QRS

14 50% 30% 10%

15 Arrhythmias 1. PSVT/AVRT Orthodromic AVRT* Antidromic AVRT 2. Atrial Fibrillation 3. Atrial Flutter


17 Irregular, Wide complex Tachycardia

18 Management Who to treat? - patients with WPW syndrome Options for treatment? - Pharmacologic Antiarrhythmics - Nonpharmacologic Radiofrequency ablation

19 Pharmacologic Mx Indications - patients who are not candidates for ablation - well-tolerated arrhythmias Choice depends on the ECG/electrophys testing and want it directed at the weak link in the conduction pathway Acute termination vs chronic prevention

20 OAVRT Weak link is the AV node (antegrade conduction) Acute Termination 1. Vagal maneuvers 2. IV verapamil (Class IV) 3. IV adenosine Chronic Prevention 1. Class IC (flecainide, propafenone) 2. Beta blockers


22 AAVRT Weak link is retrograde conduction through AV node BUT this should not be targeted unless you are 100% sure this is AAVRT Q: Why? Q: What drugs should be avoided?

23 Management WCT Avoid the ABCDs! - Adenosine - Beta Blockers - Calcium Channel Blockers - Digoxin Stable vs Unstable - Unstable- cardiovert - Stable- procainamide DDX 1. VTach 2. SVT with Aberrrancy - Antidromic WPW -WPW with AFib - MAT - A flutter - AVNRT


25 Non-Pharm Mx Ablation of Accessory Pathway - Catheter - Surgical Indications - Symptomatic tachyarrhythmias - Occupations in which development of Sxs would put themselves or others at risk - Selected asymptomatic patients


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