Intern Case Report May 29, 2015 - PowerPoint Presentation

Slide1

Intern Case Report

May 29, 2015

Sarah

Andry

D.O.

30 year old obese male

CC: dyspnea

HPI:

Started the AM after a night of binge drinking

Typically occurs after drinking

More frequent

“Feels bad” for 2-3 days afterwards

Palpitations, no CP

N

o PND/orthopnea/swelling/cough

M

edical

hx

Unknown

Reported

hx

abnormal EKG

Medications

None

NKDA

Family

hx

MI/CVA

Father- pacemaker/defibrillator in his 40s

Social

hx

Tobacco- 1ppd x 5 years

EtOH

- binge drinking several times monthly

Drugs- denies

Surgical

hx

- None

Vitals

128/85 171 20 98.3 100% RA

Physical exam

Gen: A&Ox3, NAD

HEENT: NC/AT, EOMI, MMM

Neck: Supple, trachea midline, no JVD

CV:

Tachycardic

, irregularly irregular, no murmurs

Lungs: Breathing comfortably on RA, no conversational dyspnea, CTAB

Abd

: Obese,

normoactive

bowel sounds, soft,

nontender

Ext: Radial, DP, PT pulses +2/4, no edema or cyanosis

Neuro: CNII-XII grossly intact, normal coordination, normal gait

Labs

135

4.1

11

1.63

92

102

26

7.9

14.6

219

AST 67

ALT 56

Alk

phos

53

Mag 1.99

UDS

(+)THC

(+)cocaine

(+)opiates

Adenosine 12mg

Lopressor 10mg

Diltiazem

10mg

Diltiazem

gtt

20mg/

hr

Amiodarone

150mg

Atrioventricular Reciprocating Tachycardia

Reentrant circuit (bypass pathway) + AV node

Wolff-Parkinson-White

Initial ventricular activation is slurred due to slow muscle fiber-to-muscle fiber conduction

Preexcitation

of accessory pathway that bypasses the AV node

WPW syndrome when EKG changes + symptomatic tachycardia

3.4% with WPW have 1

st

degree relative with

preexcitation

syndrome

Autosomal dominant inheritance (PRKAG2 gene,

γ

2 subunit of AMP- activated protein kinase)

Wider QRS when greater amount myocardium depolarized via accessory pathway causing delay in ventricular contraction

Delta wave

Hemodynamically unstable - cardioversion

AV nodal blockers contraindicated

May increase conduction down accessory pathway

Wolff-Parkinson-White

w

ith Atrial Fibrillation

Drug

Mechanism

Verapamil

MOST DANGEROUS

;

↑AV node refractory period, ↓myocardial contractility and SVR, reflex ↑ sympathetic tone,

↓ accessory pathway refractoriness - VF

Adenosine

Blocks AV nodal conduction

Beta Blockers

intrinsic

antegrade refractory period that was initially competing with the AV node could then become the dominant route for rapid,

antegrade

conductionAmiodarone

 has beta blocking properties, may

↑

conduction via the accessory pathwayDigoxin

Vagomimetic; ↑

AV node refractoriness and ↓

concealed retrograde conduction into the accessory pathway

Initial treatment is procainamide 20-50

mg/min

Monitor BP q5-10 min until:

- termination of arrhythmia

- patient becomes hypotensive

- QRS lengthens by 50%

- total of 17mg/kg has been givenWolff-Parkinson-White

with Atrial Fibrillation

- Radiofrequency catheter ablation when accessory pathway + tachyarrhythmia (

orthodromic

/

antidromic

AVRT,

preexcited

afib

/aflutter)- Cryoenergy as an alternative when accessory pathway is close to AV node/bundle of HisAntiarrhythmics

: flecainide, propafenone

Wolff-Parkinson-Whitewith Atrial Fibrillation

References

DiBiase

L. Wolff-Parkinson-White.

In:

UpToDate

, Post TW (Ed),

UpToDate

, Waltham, MA.

Alguire, P. C., Epstein, P. E., & American College of Physicians. (2006). MKSAP

16: Medical knowledge self-assessment program. Philadelphia, PA: American College of Physicians.Pappano

, Achilles J. Cardiovascular Physiology 10th Ed. Elsevier/Mosby, 

2013.Peter K, Pavel V, Gebauer RA,  

Materna O, Janousek J. Electrophysiologic

Profile and Results of Invasive Risk Stratification in Asymptomatic Children and Adolescents With the Wolff–Parkinson–White Electrocardiographic Pattern. Circ

Arrhythm Electrophysiol. 2014;7:218-223, published online Jan 2014.