EMS is called to the residence of a 78 year old male.
It’s the middle of the night. The patient’s spouse meets you at the front door and brings you back to the bedroom.
The patient is sitting on the edge of his bed. He is highly anxious and complaining of chest discomfort and palpitations.
Onset: During sleep
Provoke: Running made the sensation feel better earlier the previous day
Quality: An “electric” sort of “full” feeling in his chest
Radiate: The sensation does not radiate
Severity: 5/10
Time: Started earlier the previous day but went away after running
The patient takes several deep breaths during EMS evaluation and seems upset that it doesn’t correct the problem.
Skin is pink, warm, and moist.
Breath sounds are clear bilaterally.
Vital signs are assessed.
RR: 20 and shallow
HR: 100
BP: 160/98
SpO2: 98 on RA
The cardiac monitor is attached.
A 12-lead ECG is captured.
And another.
What’s going on here?
Could this be WPW?
Why or why not?
See also:
I am seeing a ventricular pacer. Lead I is concerning due to concordance with T-wave. and oppositely deflected from V6. HR doesn’t look like 76 by the way, is the pulse differentiating from the monitor?
WPW? Not unless you know something I don’t know; which you often do!
Adam -
Good eye, buddy!
The heart rate should read 100 and has been corrected. See? I used the “large block method” and hallucinated 4 large blocks!
Very good eye picking up on the pacer spikes as well!
So why does the interpretive statement suggest WPW in the second 12-lead ECG?
Tom
Looking like paced! Pacer “nubbin’s” V4-V5. If it were WPW I’d say it was a Type B due to the negative delta in V1-V2. Type A I remember as being able to draw a line through the QRS and having it look like an A, type B…well you just can’t do that
I’m thinking that the computer is missing the first half of the biphasic p-waves and the pacer spikes (I only noticed them in V4, then V5 after some staring), combined with the slow initial Q and R wave deflections, giving an impression of WPW.
Ventricular paced rhythm. Not WPW since he’s paced – any short PR would be a result of pacemaker programming and the set AV delay.
Sumthin funny with those T waves. They almost look hyperacute. A couple look like they could have p waves buried in them.
I agree that it appears to be a paced rhythm. Perhaps a on demand pacemaker, this is why he feels better when he was running. Running helps the heart to go faster thereby “turning off” the pacer.
Or I should say, Running increases the heart rate thereby “turning off” the pacer.