Dec 11, 2020
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
Guest: Jeremy Berberian, MD
- Associate Director of Resident
- 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
Residents 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.
Prevalence: 0.7 to 1.7 per
Accessory Pathway Connecting the atria to the
ventricle. In some instances, this can cause the accessory pathway
to travel FASTER than through the AV node.
down the AV node (can bypass)
AV node and UP the his-purkinje system.
Courtesy of CardioNetworks: Free use image
Image: Courtesy of EMRA EKG Guide
PR (less than 120ms)
- “Delta” wave -- which is a “slurring” of the
might be “a little” wide (still <120ms)
secondary ST-T wave changes.
Most common presentation is SVT.
But also can present as atrial fibrillation.
Key Point: Procainamide is the
most safe chemical cardioversion in WPW as it does not directly
affect the AV node. Use of AV-nodal blockers in WPW (including
Amiodarone) increases the risk of VT/VF.
***Blocking the AV node in a WPW patient in Atrial
Fibrillation can precipitate bad ventricular rhythms. If you see
A-fib GREATER than 220 minus age -- consider WPW.***
(Wide): Treat Like
Prevalence: 5 in 10,000. Traditionally taught
more common in Southeast Asian populations.
Sodium Channelopathy, which can lead to
unstable dysrhythmias and ultimately cardiac death
Diagnosis is made both by EKG
and clinical criteria
Images: Courtesy of EMRA EKG Guide
- “Coved” ST-Elevation >2mm with a negatively
deflected T in right precordial leads (V1-V3)
- Potentially diagnostic as isolated EKG
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
- Nocturnal Agonal Respirations
- Brugada gets WORSE with parasympathetic
- Family member with known Type 1
- Observed/Documented VT/VF
- Sudden cardiac death in family member <45
(Take that history!)
Arrhythmogenic Right Ventricular
Prevalence: Unknown, likely more
than we thought. Mean age is 31. Also we don't have great clinical
criteria to full encompass this -- yet. Multiple genes linked to
disease process. Variable inheritance patterns.
Fibro-Fatty infiltration of the myocardium that
replaces good "conductive" tissue with fibrinous infiltrates.
Think: "Kinda like cirrhosis of the heart."
Causes paroxysmal ventricular
rhythms. Can present as CHF.
Courtesy of EMRA EKG Guide
- Epsilon wave -- AKA "The Ditzle or Nubbin" (only in 30% of
- T-wave inversions in right precordial leads (V1-V3) -- (85% of
- Long S-wave repolarization delay >55ms (in 95% of
- Slightly prolonged QRS >110ms (Right precordial leads)
- VT looks more like a Left-bundle morphology -- Appreciate that
AFTER the patient is out of VT.
Key Resources: *If needed and/or different than
- Clinical Policy: Critical Issues in the
Evaluation and Management of Adult Patients Presenting to the
Emergency Department with Syncope: Huff J.S., Decker
W.W., Quinn J.V., Perron
A.D., Napoli A.M., Peeters S., Jagoda
A.S.( 2007) Annals
of Emergency Medicine,
49 (4) , pp. 431-444.
- Epidemiological profile of
Wolff-Parkinson-White syndrome in a general population younger than
50 years of age in an era of radiofrequency catheter
C.-W., Wu M.-H., Chen
H.-C., Kao F.-Y., Huang
S.-K. (2014) International Journal of
(3) , pp. 530-534.
- Reference, G. (2019). Brugada syndrome. [online] Genetics Home Reference. Available
[Accessed 14 Feb. 2019].
- McNally E, MacLeod H, Dellefave-Castillo L.
Arrhythmogenic Right Ventricular Cardiomyopathy. 2005 Apr 18
[Updated 2017 May 25]. In: Adam MP, Ardinger HH, Pagon RA, et al.,
editors. GeneReviews® [Internet]. Seattle (WA): University of
Washington, Seattle; 1993-2019. Available from: