Flashback Friday: Lumps and Bumps: Can’t-Miss Diagnoses in Syncope

EMRA*Cast

Dr. Jeremy Berberian joins EMRA*Cast with Alex Kaminsky to delve deeper into the pathophysiology and electrical findings associated with diagnoses such as WPW, Brugada and ARVD.

Lumps and Bumps: Can't-Miss Diagnoses in Syncope

Host: Alex Kaminsky

Guest: Jeremy Berberian, MD

• Associate Director of Resident Education, ChristianaCare
• Editor-in-chief: EMRA EKG Guide, EMRA Ortho Guide, and the upcoming Emergency ECGs: Case-Based Review and Interpretations, with Amal Mattu and William Brady
• Faculty editor: EM Resident Monthly ECG Challenge
• Creator: ECG Greeting Cards©, a collaboration with MPP and JerBer Productions

EPISODE OVERVIEWResidents are well-programmed to recognize cardiovascular emergencies such as STEMIs at a glance. However, during a busy shift it can be easy to overlook dysrhythmias and other electrophysiologic urgencies and emergencies. Syncope is a prime example of a chief complaint that may be uncovered with an EKG alone -- however, syncopal emergencies are often subtle and nuanced. Dr. Berberian joins EMRA*Cast with Alex Kaminsky to delve deeper into the pathophysiology and electrical findings associated with diagnoses such as WPW, Brugada, ARVD and more.

KEY POINTS

Wolff-Parkinson-White (WPW)

Prevalence: 0.7 to 1.7 per 10000

OverviewAccessory Pathway Connecting the atria to the ventricle. In some instances, this can cause the accessory pathway to travel FASTER than through the AV node.

• Orthodromic (Narrow): Travels down the AV node (can bypass)
• Antidromic (Wide): Bypasses AV node and UP the his-purkinje system.

Courtesy of CardioNetworks: Free use image

Key Features:

Image: Courtesy of EMRA EKG Guide

• Short PR (less than 120ms)
• “Delta” wave -- which is a “slurring” of the QRS complex
• QRS might be “a little” wide (still 2mm with a negatively deflected T in right precordial leads (V1-V3)
• Potentially diagnostic as isolated EKG finding.

Type 2:

• ST elevation in right precordial leads (V1-V3) with a “saddleback.” Within the STE.

• Not completely diagnostic but concerning fr workup.

Clinical Criteria (EKG Findings PLUS one or more):

• SYNCOPE
• Nocturnal Agonal Respirations
• • Brugada gets WORSE with parasympathetic stimuli.
• Family member with known Type 1
• Observed/Documented VT/VF
• Sudden cardiac death in family member