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.

2019 3-3.jpeg


1.     What does the EKG demonstrate?

 2.     How would you manage this patient?


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.

2019 3-3b.jpg

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.

EKG of the Week 2018-6-10

This EKG comes courtesy of Dr. Kong.

A 60 y/o male with hx of HTN, presented for palpitations.

V/S: P - 140, BP 180/90, R - 18.

Two EKG's are below. EKG a was the first EKG.

2018 6-10a.png

EKG b was taken after the patient was given diltiazem.

2018 6-10b.png

1.       What rhythm is demonstrated in EKG a?

2.       What other pattern is demonstrated in EKG a?

3.       What happened to the QRS complexes between EKG a and EKG b?



The rhythm is atrial fibrillation with a rapid ventricular response. 

There is a left bundle branch block

The bundle branch block went away. This is known as a rate related bundle branch block.


The first EKG shows rapid a-fib with a left bundle branch block. The patient was treated with diltiazem with resultant control of the heart rate. When that happened the bundle branch block disappeared and the QRS narrowed. This is known as a rate related bundle branch block.

As the heart rate increases, the cardiac cycle shortens. Eventually the next beat arrives when one bundle is still refractory. So it conducts down the other bundle and then across the heart, the same as in a regular bundle branch block. However, when the heart rate slows, the cardiac cycle lengthens and the bundle recovers. When the bundle recovers the bundle branch block disappears.

No specific treatment is needed for a rate-related bundle branch block.