A Little Cardiology Geekery

Wolff Parkinson White Syndrome is a rare cardiac conduction disorder that affects less than 3% of the human population.

In fifteen years as a paramedic, I’ve seen it twice. Both of those times, the victim was over 40 years of age before being diagnosed.

Weird, that.

The first victim was a 52-year-old woman who had gone for years without an explanation for her frequent syncopal episodes. CT scans, ECGs, MRIs, a number of occasions where she wore a Holter monitor for 48 hours or more… all of them revealed nothing other than her baseline rhythm of atrial fibrillation, right up to the day she suffered one of those syncopal episodes while attached to my cardiac monitor.

One cardioversion attempt later, she was back to good old atrial fib, none the worse for wear. My partner and her husband had to change their shorts, but I, stalwart EMS professional that I am, remained stoic and utterly unflappable the entire time.

Rumors that I squealed like a little bitch and forgot to use the gel conductive pads before shocking her are entirely unfounded. Srsly.

But in the fourteen years and untold number of patients since, I’ve never encountered another case until last week, at least not when there was an active problem that required intervention. Of course, there is also the possibility that I saw a lot of it early in my career and was too ignorant to recognize it for what it was.

During those years, I have formed a few opinions about management of abnormal heart rates in the field:

  • Hemodynamically unstable rate problems are best treated with electricity, not those selective cardiotoxins we call antiarrhythmics.
  • Conversely, hemodynamically stable tachycardias are best treated with diesel fuel and tincture of time, and perhaps PFT Therapy.
  • Instability in any patient with a rate problem has less to do with the actual number on your monitor than how your particular patient is dealing with it. Some people with a rate of 160 are infinitely sicker than the guy with a rate of 220.

Most of the people I use adenosine on could easily wait another five minutes until they arrive at the ER. Honestly, I push it to placate the ER doctors and nurses. Ditto for Cardizem. Oh, it’s clinically indicated every time I give it, but the patient is rarely so sick that “watch and wait” could not be considered a viable alternative. I rarely give lidocaine or amiodarone outside of arrest situations because most ventricular tachycardias are better treated with cardioversion.

Hence, the therapeutic electrocutions. If a patient is so sick that they have to be treated in the field, nine times out of ten, that treatment oughta be transcutaneous pacing or synchronized cardioversion.

To a great degree, I think a lot of my colleagues have it backwards; they think nothing of pushing selective cardiotoxins antiarrhythmics, yet have an almost mythical fear and loathing of electrical therapy.

Me, I’m just the opposite. There have been times when I’ve unsuccessfully tried pacing or cardioversion, but I can safely say that, if it had an undesired effect, I’ve never had to thumb through a Nursing Drug Reference to find out how long it takes someone’s liver and kidneys to metabolize and excrete a jolt of electrical current.

So flash forward to last week, when I met my second WPW patient. She’d been diagnosed five years prior, but had never had a tachycardic episode prior to that night. When it hit her, she promptly passed out. She came to a few seconds later, complaining of 10/10 chest pain and difficulty breathing. Her BP was okay at 112/64, but she looked like crap…

… which, to an experienced clinician, is an even more reliable indicator of instability than the blood pressure.

She was lethargic and weak, but coherent, so I was able to get a pretty fair history as I attached the cardiac monitor and Rookie Partner got vital signs.

So when I had all my ducks in a row, I lit her up like a Christmas tree:

A few observations from the event and the war stories afterwards:

  • When a patient tells you, “Oh, no nasal sprays! I’ll throw up!”, it’s best to believe her and hold off on the intranasal Versed. Better to spend an extra couple of minutes to find a vein and give it intravenously.
  • Synchronized cardioversion works much better if you actually hook the hands-free pads to the patient cable. Plus, you get the added benefit of not looking like a goober. But it gives your partner a cool war story of his own, and he has so few, the poor kid…
  • A forty year old woman, when hit with 100 Joules of current, will make a sound exactly like Macho Man Randy Savage. For the past week, RP and I have been giggling like fiends and saying “Oooooh yeah, snap into a Slim Jim!”
  • Most of my colleagues, when faced with the same patient, would have given her adenosine or Cardizem. And quite possibly have killed her in doing so. One does not suppress the normal conduction system when the patient has an abnormal accessory pathway that is much faster, kiddies. That’s a helpful tip from your Uncle Ambulance Driver.

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