224 ) A 38 year old man presents to the emergency room with complaints of palpitations that started 5 hours ago and are persistent. He denies having similar episodes in the past. He has no fever or shortness of breath or chest pain. His past medical history is unremarkable and he is not on any medications. On examination, blood pressure is 110/60 mmHg, heart rate 130/min, RR 20/min and temperature 98.6 F. Cardiovascular examination reveals irregularly, irregular heart rate at 140beats/min. An Electrocardiogram now is shown below :
An EKG that was done during a pre-employment health check-up upon patient’s own request two months ago is shown below:
The most appropriate next step in managing this patient:
A) Defibrillation
B) Intravenous metoprolol
C) Intravenous Diltiazem
D) Intravenous Procainamide
E) Synchronized Cardioversion
(Option D) V-Tach in the setting of a patient with WPW suggestive by the ekg obtained 2 months ago. This patient is hemodynamically stable, so no cardioversion is indicated.
C
Correct answer is D
Where can we find the answers plz
V-tach and supra Vtach, boost up with IV Procainamide
A
It is a wide complex tachycardia so do you think it is v.tach or SVT?
it’s WPW syndrome delta wave
SVT
I think
ya SVT
VT superimposed in WPW individual
Most of you are correct. The patient is presenting with wide complex tachycardia which is irregular i.e; atrial fibrillation that can be seen in WPW syndrome which appears with wide QRS complexes. Note that his EKG two months ago at baseline shows clear “delta” waves suggesting pre-excitation accessory pathway and also, short PR interval and wide QRS that are classically seen with WPW syndrome. Patients with WPW syndrome may remain asymptomatic for long periods but can present with palpitations secondary to tachyarrhythmias such as atrial fibrillation or SVT. In this case, patient presents with atrial fibrillation. Using calcium channel blockers or beta blockers or diltiazem will block the conventional AV pathway and do not do anything to block the accessory pathway. So, accessory pathway will remain active and hence, these drugs may further worsen the condition. Do not use beta blockers or calcium channel blockers in the treatment of atrial fibrillation secondary to WPW. Treatment of choice is procainamide.
Cardioversion is indicated if the patient has unstable atrial fibrillation i.e; symptomatic with chest pain or sob or if there is hypotension. Defibrillation is treatment used in pulseless ventricular tachycardia or in ventricular fibrillation. Though this is wide complex , this is not a ventricular tachycardia since WPW associated supra-ventricular tachycardia is also wide-complex rhythm.