Thanks to Dr. Schiappa for this case and Dr. Isserman for his wisdom
21 year old female with no pmh presents to the ED after syncopal episode. She denies pre-syncopal symptoms and currently feels well. Witnesses deny seizure activity. She regained consciousness within a minute. No head trauma.
Physical exam is unrevealing
What is the definitive management for this patient?
- IV hydration
- Cardiac Ablation
- Cardiac catheterization
C- This patient has Wolf-Parkinson- White or WPW
While the delta wave isn’t the most evident on the EKG(seen best on V3), the PR interval is 116 (<120) which is highly specific for an accessory pathway (pre-excitation). WPW is the classic accessory pathway that we learn about with the short PR interval, delta wave, and prolonged QRS, this pathway is called the bundle of kent. Lown-Ganong-Levine or LGL is another accessory pathway syndrome, characterized by shortened PR and normal QRS and the absence of a delta wave.
The definitive management is done through EP studies and ablation of the accessory pathway.
Things you look for in a EKG for a patient with syncope:
First establish sinus rhythm, rule out Vtach, SVT, and 3rd Degree Heart Block
Then Look At:
PR Interval- Short (acessory pathway), Long/Changing (Type II 2nd Degree)
QTC- Long (risk for Torsades)
LVH (AS, or HCM)
Right Heart Strain/S1Q3T3 (evidence of PE)
Voltage/Electrical Alternans (Pericardial effusion and tamponade)