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A 55 year old woman is brought to the emergency department after a syncopal episode. She is semi-conscious, cyanotic, tachypneic and hypotensive with a blood pressure of 70/40. She has the following EKG. What treatment that you gave produced a prompt improvement in her condition. What does the EKG show and what is the diagnosis? Rate: 220 Rhythm: Atrial fibrillation Axis: Left axis P: not seen QRS: broad, bizarre Additional waves: delta waves EKG diagnosis: Atrial fibrillation with aberrant conduction Clinical diagnosis: Atrial fibrillation Wolff-Parkinson-White syndrome Treatment: Immediate synchronized cardioversion is the treatment.
Practice Points: -this EKG is totally irregular and P waves are not seen confirming the diagnosis of atrial fibrillation -The QRS complexes have a distinctive slurred upstroke of the R wave---the delta wave -In patients without an accessory pathway the AV node protects the ventricles from very rapid atrial discharges during atrial fibrillation. However, in WPW syndrome the presence of an accessory pathway bypasses the AV node and may result in a very fast ventricular rate. This may lead to heart failure or hemodynamic compromise. The faster the ventricular rate, the greater the risk of ventricular fibrillation. -In this EKG, the majority of impulses are conducted via the accessory pathway and therefore a delta wave is present. Some impulses however may be conducted normally through the AV node and will appear normal.
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