You are catching up on some charts in the resuscitation area of your ED when your triage nurse pushes in a 37 yo M with no PMHX, who presented to your ED complaining of sudden onset lightheadedness and L sided chest pain about 10 minutes PTA while at rest. No prior episodes. No CAD risk factors. No illicit drug use. No family risk factors. The patient appears uncomfortable, diaphoretic and is clutching his chest.

Vitals at Triage:

Pulse 215

BP 87/60

RR 18

SpO2 100% NRB

As your patient is being attached to the monitor, you quickly assess ABC’s and perform a rapid exam. The patient is protecting his aware, lungs are clear bilaterally, and his hands feel cool. He’s AAO3.

Your ER tech then hands you this…


Features of WPW with AF:

– Irregular

– Wide-complex

– Chaotic, heterogeneous appearing QRS complexes

– Slurred upstroke of QRS in some leads

So you’ve got yourself a irregular, wide-complex tachycardia with a pulse. Now you got to ask yourself.

Stable or Unstable?

This patient definitely falls on the unstable side of the spectrum.

  • Hypotension? YES
  • Signs of end-organ dysfunction/damage:
    • Altered mental status? NO
    • Ongoing CP? YES
    • Signs of heart failure? NO

* Mini-Pearl: If any one of these is YES, the patient is unstable.

You have your first UNSTABLE, WIDE-complex tachycardia ever. So, what do you want to do, uh-um, doctor?


You are darn right you want to shock this patient. Look at that, your amazing ER tech has already placed the pads on. And what’s that? Your amazing Attending has already QUICKLY verbally consented the patient and drawn up LIGHT sedation and pain medications. So… what settings would you like?

You go with synchronized cardioversion at 150J biphasic. The patient goes into sinus rhythm, vitals normalize and the patient feels a lot better. This was the subsequent ECG.

Pearl Ekg2


– Short PR interval

– Broad QRS

– Delta wave

Note: there are STE in aVR and V1, with diffuse STD. Cath lab was consulted. These changes were deemed to be rate-related and normalized in a subsequent EKG