EKG of the Week 2019 6-2

This EKG comes courtesy of Dr. Pilat.

 

A 5 month old boy presented to the ED with intermittent fast heart rate observed by the mother. No change in the level of activity or alertness, normal feeding, no SOB or any other additional complaints. No recent illness. Physical exam revealed a well-appearing, well-nourished baby boy, smiling, playful, active, good eye contact, normal work of breathing, no retractions, lungs CTA b/l, tachycardia, abdomen soft NT/ND, normal skin color and temperature, no cyanosis, capillary refill<2 sec.

V/S: P – recorded at triage as 148, R 28, BP 85/59

The EKG is below.

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1.     What does the EKG demonstrate?

2.     How would you manage this baby?

ANSWER:

The EKG demonstrates a regular narrow complex tachycardia at a rate of approximately 220 with absent P waves. This is consistent with SVT.

 Infants in SVT can be managed with vagal maneuvers. If they are unsuccessful, give adenosine 0.1 mg/kg.

 

This patient received 3 doses of adenosine (0.1, 0.2, 0.2) and then converted.

The post-conversion EKG (below) shows a sinus rhythm with tall P waves (best seen in leads II, III, aVF, V1 and V2) consistent with right atrial enlargement. There is also a short PR interval with a delta wave (best seen in leads V4-V6) consistent with pre-excitation.

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This patient had Ebstein’s anomaly. This is a congenital malformation of the tricuspid valve where the valve is located “too low” in the right ventricle. This results in the upper portion of the right ventricle effectively becoming part of the right atrium (known as “atrialization of the right ventricle”). The functional portion of the right ventricle is very small. Most patients with Ebstein’s anomaly also have tricuspid regurgitation and an atrial septal defect.

Patients with Ebstein’s anomaly often present with cyanosis and signs of right-sided heart failure. They are also at risk for arrhythmias including narrow complex SVT, wide complex tachycardia, a-flutter, a-fib, v-tach and sudden cardiac death.

The abnormal tricuspid valve results in direct muscle connection from the right atrium to the right ventricle. This can serve as an accessory pathway which puts the patient at risk for pre-excitation arrhythmias (WPW). 10-25% of patients with Ebstein’s anomaly will have WPW.

Management of arrhythmias in patients with Ebstein’s anomaly is the same as in the general population.

 

This patient was admitted to the hospital and seen by pediatric cardiology. Her echo showed mild to moderate tricuspid regurgitation, normal RV pressure, dilated right atrium.

She was started on propranolol and discharged home.

 

 

(Attenhofer Jost, et al. Ebstein’s Anomaly. Circulation. 2007;115:277-285)

(Loomba et al, Association of Atrial Tachycarrhythmias with Atrial Septal Defect, Ebstein’s Anomaly and Fontan Patients. Expert Review of Cardiovascular Therapy 2011;9:887.)

EKG of the Week 2019 3-3

This EKG comes courtesy of Dr. Mohammad Hassan and Dr. Husain.

A 30 Year old male with a history of panic attacks presented to the ED complaining of palpitations and SOB. He states it began after drinking iced tea and coffee. He did not syncopize. He denied chest pain, nausea, vomiting.

He appears lethargic with a waxing and waning mental status.

Vital signs: Pulse – 230, Respirations – 20, BP – 90/50.

His EKG is below.

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1.     What does the EKG demonstrate?

 2.     How would you manage this patient?

ANSWER:

The EKG shows a wide complex tachycardia.

The patient is unstable. The appropriate treatment is electrical synchronized cardioversion.

 

The EKG shows a wide complex tachycardia. That should be treated as v-tach until proven otherwise. In this case, the rhythm is irregular. V-tach should be regular. When you see a very fast irregular wide complex tachycardia, it raises the concern for a-fib with underlying WPW.

The patient was unstable so he was treated with electrical cardioversion. His post-cardioversion EKG is below. It shows a sinus rhythm with a short PR interval and a delta wave consistent with WPW.

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It was later discovered that the patient had a history of WPW and had a previous ablation.

WPW puts patients at risk for tachyarrhythmias. SVT is the most common arrhythmia in WPW. A-fib is the most dangerous arrhythmia in WPW. It can lead to unopposed conduction down the accessory pathway which can lead to V fib. 

Patients with a-fib in WPW who are unstable should be treated with electrical cardioversion. Patients who are stable should be treated with procainamide.

Our patient was treated with cardioversion and he converted to sinus rhythm. He became more stable. He was admitted to telemetry and had an ablation performed.