EM Alliance ECG – Case 6

32 YOM, dizzyness

 

ECG courtesy of  http://www.emalliance.org/

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4 Comments Add yours

  1. Tatsu Kuwasaki says:

    AHA guidelines states:

    A wide-complex irregular rhythm should be considered pre-excited atrial fibrillation. Expert consultation is advised. Avoid AV nodal blocking agents such as adenosine, calcium channel blockers, digoxin, and possibly β-blockers in patients with pre-excitation atrial fibrillation because these drugs may cause a paradoxical increase in the ventricular response. Typically, patients with pre-excited atrial fibrillation present with very rapid heart rates and require emergent electric cardioversion. When electric cardioversion is not feasible or effective, or atrial fibrillation is recurrent, use of rhythm control agents (discussed below) may be useful for both rate control and stabilization of the rhythm.

    https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-7-adult-advanced-cardiovascular-life-support/

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  2. Tatsu Kuwasaki says:

    When AF of super fast rate 250~300bpm, we must think of the preexcitation due to accessory pathway such as WPW.
    Because it’s so fast, it could look regular and P-waves, Delta waves would probably not be recognisable and it may have an appearance of VT or SVT.
    I’m sure the decision comes easy for you to cardiovert if it looks like VT, or even SVT, and patient is severely compromised.
    However, there is a severe potential consequence if you treat with amiodarone or adenosine if moderately compromised.

    ABCD (A=Adenosine, B=Beta-blocker, C=Calcium Channel Blocker, D=Digoxin) all have AV nodal blocking properties and they are contraindicated.

    Amiodarone is not contraindicated under our CPG or AHA guidelines 2015.
    However, Amiodarone has multitude of effects including the AV nodal block.

    If you block AV node which is acting as a safety mechanism and delaying some of the chaotic atrial firing, the super fast electrical impulse will be passing through the accessory pathway (Kent bundle) that result in VT or VF.

    If you understand the mechanism of the risk of AV nodal blockers, and having the lethal consequence potential, it makes sense for us to be super cautious about the use of Amiodarone to the WPW patients with AF.

    Please check out my usual favourite Dr. Mattu below!

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  3. Tatsu Kuwasaki says:

    How did you go with this ECG interpretation?

    I’ve been impressed with the depth of knowledge our crew have even at EMT level after speaking with a couple of you guys.

    The short answer is, AF with WPW.

    There are not many irregular WCT (Wide complex tachycardia), in fact we should be thinking two potentials.

    1. AF with aberrancy ie. BBB.
    2. AF with preexcitation ie WPW
    * Due to age, PMHx should lead you to think this patient is unlikely to have BBB.

    https://lifeinthefastlane.com/ecg-library/pre-excitation-syndromes/

    OK, so how do you treat this patient if he was moderately or severely compromised?

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