WPW on the 12 Lead EKG – a Potential Literal Death Trap

When it comes to a 12 lead EKG, finding WPW is not common. WPW is a syndrome of intermittent tachycardia in patients with a short PR interval and a widened QRS complex. When reading 12 lead EKGs or treating tachyarrhythmias, this can be a literal death trap.

Looking at WPW

This genetic problem means there is an extra pathway in the heart that allows the conduction of electrical impulse
from the atria to get to the ventricles via a faster pathway – thus the PR interval is less than 0.12 seconds.

This accessory pathway means, if we use a traditional negative chronotrope that blocks the AV node, we make them sicker. In this case, a CCB was tried. It didn’t work. That would have been a flag to me. Then, a BB was tried. That didn’t work either. Now it would have been a billboard (bigger then a flag). Then digoxin completely shut the AV node conduction off and put the patient into VT. So, the lack of response to standard treatments for a presumed A.Fib should have been a moment to pause and reset the initial diagnosis. It’s a cognitive error called “premature closure.”

Recognizing WPW

But, how could we know? How could we know if the patient indeed has an accessory pathway? The big identifier is the wide complex nature of the rhythm. That needs to be a flag. New onset of a wide complex irregular rhythm must be considered WPW until proven otherwise.

Treatment would clearly be to defer to the powers that be. As a PA, this is high risk stuff. AND… this is a good thing about being a PA. We have the responsibility to seek advice from our supervising physician.

Yet, I would treat this with Amiodarone. Call 1a antiarrhythmic (Procainamide) is also an option.