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Interesting Case Rounds

Interesting Case Rounds. Alyssa Reed R1 Emergency Medicine. CASE #1. 16F presenting with 2 syncopal episodes over the last two days PMHx: chiari malformation, chronic back pain Meds: Naprosyn Vitals at Triage: 80 16 106-60 96% 5.5 Q: What else would you like to know?

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Interesting Case Rounds

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  1. Interesting Case Rounds • Alyssa Reed • R1 Emergency Medicine

  2. CASE #1 • 16F presenting with 2 syncopal episodes over the last two days • PMHx: chiari malformation, chronic back pain • Meds: Naprosyn • Vitals at Triage: 80 16 106-60 96% 5.5 • Q: What else would you like to know? • Q: What is your approach to this patient?

  3. Syncope DDx • Focal Hypoperfusion of CNS Structures • SAH • Hyperventilation • Systemic Hypoperfusion Resulting in CNS Dysfunction • Outflow Obstruction • CHD • valve stenosis • Reduced Cardiac Output • WPW • SVT • Tachycardias • Bradycardias • Long QT syndrome • Aortic dissection • Cardiomyopathy • Vasomotor • Other CNS Dysfunction • Hypoglycemia • Seizure • Toxic

  4. Findings • O/E: AVSS, no significant findings • N S1S2, no murmurs, no extra sounds, no JVD, no pulse delays, pressure same both arms, normal neuro exam • Labs: CBC, Lytes, Ca, Mg, PO4 normal • CXR: no cardiomegaly • ECG........

  5. Dx???

  6. WPW • Definition: a preexcitation of the ventricles through an accessory pathway- the Bundle of Kent- which provides an abnormal pathway of electical communication between the atria and the ventricles • WPW Pattern: ECG abormalities • WPW Syndrome: ECG abnormalities and associated arrhythmia • AVRT (80%) • Atrial Fibrillation (15-30%) • Atrial Flutter (5%)

  7. Prevalence • WPW Pattern • 0.15-0.25% in general population • 0.55% among first-degree relatives of affected patients • in one large study it was 2x more prevalent in males • WPW Syndrome • approx 1% with pattern have arrhythmia • review of 22500 showed .25% had pattern but only 1.8% of these had a documented arrhythmia • sudden death: 0-.39% annually

  8. CASE #2 • 8F presenting with several episodes of “black-outs” that she remembers dating back to when she was two. None witnessed. • PMHx: healthy, no meds • FHx: mom has some unknown heart condition- she was treated with something that ends in “lol” • O/E: no significant findings • Q: would you do an ECG?

  9. Familial WPW • WPW syndrome- 3.4% have 1st degree relative with preexcitation syndrome • much lower than I expected • Usually inherited as autosomal dominant trait • Can also be associated with a familial hypertrophic cardiomyopathy

  10. Pathophysiology/ECG • Bundle of Kent is a muscle fiber accessory pathway that directly connects the atria and the ventricles • conduction down this pathway is faster allowing ventricular activation earlier but occurs at a slower speed • Q: What are the basic ECG findings in sinus WPW? 1. PR is short 2. Delta wave 3. Wide QRS

  11. 1. Short PR due to rapid conduction through the accessory pathway and bypass of the AV node 2. Delta Wave upstroke slurred because of slow muscle fiber-to-muscle fiber conduction 3. Wide QRS fusion between early ventricular activation and the normal activation through the normal pathway

  12. **the more rapid the conduction along the accessory pathway, the greater the amount of myocardium depolarized via the accessory pathway, resulting in a more prominent or wider delta wave, and longer QRS

  13. 10% 10% 50% 30%

  14. Arrhythmias • PSVT/AVRT • Orthodromic AVRT* • Antidromic AVRT • Atrial Fibrillation • Atrial Flutter

  15. Irregular, Wide complex Tachycardia

  16. Management • Who to treat? • patients with WPW syndrome • Options for treatment? • Pharmacologic • Antiarrhythmics • Nonpharmacologic • Radiofrequency ablation

  17. Pharmacologic Mx • Indications • patients who are not candidates for ablation • well-tolerated arrhythmias • Choice depends on the ECG/electrophys testing and want it directed at the “weak link” in the conduction pathway • Acute termination vs chronic prevention

  18. OAVRT • Weak link is the AV node (antegrade conduction) • Acute Termination • Vagal maneuvers • IV verapamil (Class IV) • IV adenosine • Chronic Prevention • Class IC (flecainide, propafenone) • Beta blockers

  19. AAVRT • Weak link is retrograde conduction through AV node • BUT this should not be targeted unless you are 100% sure this is AAVRT • Q: Why? • Q: What drugs should be avoided?

  20. Management WCT DDX 1. VTach 2. SVT with Aberrrancy - Antidromic WPW -WPW with AFib - MAT - A flutter - AVNRT • Avoid the ABCDs! • Adenosine • Beta Blockers • Calcium Channel Blockers • Digoxin • Stable vs Unstable • Unstable- cardiovert • Stable- procainamide

  21. Non-Pharm Mx • Ablation of Accessory Pathway • Catheter • Surgical • Indications • Symptomatic tachyarrhythmias • Occupations in which development of Sxs would put themselves or others at risk • Selected asymptomatic patients

  22. QUESTIONS?

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