WPW Cases

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Mel tests our knowledge on WPW with three different cases. Boom! 

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Dr. Metal -

Like this format of a "mini series" for learning. Perfect for us ADHD EM types.

Mel H. -

Now I know there are at least two people in the world that believe this :)

Adam R. -

Can you spend a little more time on the first case, I do note slightly different morphologies of the QRS but to say one is wide and one is narrow is a difficult call for me. Any concerns with cardioverting someone in afib and then an embolic effect?

Mel H. -

The example I used on that video I have to agree there is NOT as much QRS width variation as you can often see. The faster the rate the less the variation in my experience. But they are clearly NOT all the same shape like a "normal " atrial fibrillation without a bypass track. We know from Ian Stiell's data from Ottawa and others that less than 48 hours of atrial fibrillation clot/stroke risk is low with cardioversion with new onset atrial fibrillation. In the case of atrial fibrillation and WPW usually these patients feels so bad, so like they are going to die, they present really early and I have NO anxiety about cardioversion as embolic risk is low and that arrhythmia is potentially lethal at any time!

Adam R. -

If I would not have the idea that this is an accessory pathway from WPW but rather perhaps an a-fib with rvr with off and on aberrancy, and if a calcium channel blocker was used to try to slow the rate, would this be an example of slowing the rate of conduction through the av node therefore allowing all the conduction through the fast alternate conduction pathway and now making the ventricular rate even faster and the patient more unstable? What are the safe medications that could be used in this scenario?

Mel H. -

Right the differentials is AF with some intermittent BBB or AF with WPW. Most of the time I am not smart enough to know which is which. Classically it is said use Procainamide (to slow accessory pathway conduction) - then add an AV blocker (that is complicated and time consuming) I think if in doubt, cardiovert. AV blockers in the face of WPW AF often cause VF. So if you are not sure I think cardioversion is best- but even here people can arrest - WPW is out to get you!

Adam R. -

Thank you

Kenneth D. -

Could you explain why the QRS in Case 2 was narrow. It looked wide to me. Thanks for your attention.

Natascha N. -

Same here

Matia M. -

Just updated the ECG graphic for this case to a better one.

Mel H. -

You are right. It looks like it could be wide. I will get a better example. The vertical format can also modify the way it looks a little.

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