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Morning Report: Emergency Medicine Wolff-Parkinson-White

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A classic resting state EKG of WPW. Reviewing treatment options in both the resting and tachydysrythmia states.

Welcome to this episode of morning report emergency medicine i’m alec we’re this is the case of the wolf pack a 17-year old male reports acute onset of palpitations with shortness of breath and mild lightheadedness today it resolves spontaneously after 20 minutes and he had a similar episode a year ago but that one resolves spontaneously as well his temperature is

36.7 heart rate of 64 blood pressure of 134 over 67 breathing 16 times a minute satting a hundred percent on room air and what’s the differential diagnosis 17 year old male with palpitations things like electrolyte abnormalities thyroid disease arrhythmias drugs anxiety it’s all on table and here’s his ekg and when we’re talking about ekgs and young healthy people

Especially if they’re having symptoms of palpitations or syncope you gotta pay close attention to the intervals whether it’s a brugada syndrome with an incomplete right bundle branch block and a slightly widened qrs or prolonged qt and congenital prolonged qt syndrome or short pr’s let’s take a look at this ekg he’s beating right around 60 beats per minute normal

Axis at normal sinus rhythm pees before every qrs is qrs is after every pees but look at that pr interval that pr interval is short really short and why is it so short well it’s because of that delta wave that’s present it’s president almost every single lead of course we’re talking about wolff-parkinson-white syndrome look for that short pr interval and the reason

You have that short pr is because of the delta wave because of the accessory pathway that exists between the atria and the ventricles and the delta wave may not always be present but the short pr is the key and here classic what is wolff-parkinson-white syndrome it’s a pre excitation syndrome there’s an additional or accessory av pathway causes palpitations syncope

Even v-fib arrest or afib and the key to wolff-parkinson-white is that short pr on the ekg you can have that delta wave you can have t wave abnormalities usually you’ll have a dominant r wave in v1 and v2 and you also may have some inferior q waves but they’re not pathologic q waves of an mi here’s our ekg again we see that short pr interval in every lead and we

Also see that delta wave that up the slope here at the beginning every qrs we don’t have that dominant are wave in v1 to v2 we actually have a large s wave that’s because this is a type b wolff-parkinson-white syndrome so how do you treat this well if they’re an arresting ekg like we have here you can put them in an anti-arrhythmic but if it’s unstable they’re in

An a feather a tacky dysrhythmia or they’re in shock you cardiovert them and the antiarrhythmics well you need antiarrhythmics that prolong the accessory pathway things like a mio or procainamide fleck an id or perp afaa known you avoid drugs that shorten the refractory period like didge also medications that shorten conduction between the atria and the ventricles

Leaving only the accessory pathway like verapamil or lidocaine beta blockers really have no effect on this accessory pathway long term these patients need an ablation of that accessory pathway this patient was started on propafenone was at a class 1c anti-arrhythmic it’s a sodium channel antagonist him and his family are currently conveying the consideration of

Ablation therapy our take-home points the differential palpitations of course arrhythmia is on that list and with this case of wolff-parkinson-white syndrome you want to look for that short pr interval and the delta wave if they’re unstable if they’re in shock give them a shock and then for antiarrhythmics you want things that will prolong the accessory pathway

Things like a mio or procainamide and procainamide is really the one i want to hit home fleck a night or propafenone avoid things like for wrap a meal de jour beta blockers as always you can follow me at we’re underscore alec on twitter or subscribe to this channel for more updates from morning report emergency medicine keep your eyes out for those interesting cases

Transcribed from video
Morning Report: Emergency Medicine Wolff-Parkinson-White By Alec Weir