SYNCOPE

Question 1

DDX

Answer 1

Basic Things:
Arrythmia
Ischemia

Exotic Things:
Arrythmogenic Right Ventricular Dysplasia (epsilon waves, flipped t waves V1-V3)

Brugada (RBBB, STE, V1-V3)

Left Ventricular Hypertrophy (marked high voltage)

Pulmonary Embolism (Right axis shift, S1Q3T3, RBBB, Deep flipped t waves V1-V3)

QT too long / too short (Qt > 1/2 RR)

Wolf-Parkinson White

HOCM

Bifascicular Block

Question 2

Brugada Sydrome: Criteria
Management

Answer 2

ECG CRITERIA:

“RBBB with STE in V1-V3”

RBBB in V1-V3

J-point elevation

Saddle shaped or sloped ST segment elevation

Inverted t wave

MANAGEMENT:

Stable: close outpatient follow up with cardiologist
Unstable or drop attacks: admission and monitoring with cardiology consultation
Strict instructions to aboid QT prolonging drugs

Question 3

Long-QT Syndrome: Criteria

Answer 3

QT Greater than 470 ms in men
QT greater than 480 ms in females

QTc increases the risk of arrythmia: > 500 ms

Question 4

HOCM

Answer 4

Large amplitude QRS

Left ventricular hypertrophy with increased precordial voltages

non-specific ST segment and T-wave abnormalities

Deep, narrow (“dagger-like”) Q waves in lateral (I, aVL, V5-6) and/or inferior (II, III, aVF) leads

Question 5

Pulmonary Embolism

Answer 5

1) Sinus Tachycardia
2) Right Axis Deviation
3) Incomplete or complete RBBB
4) Right Ventricular Strain Pattern:
T wave inversion inferior and anteroseptal leads
5) S1, Q3, T3 Pattern:
Large S wave in lead I
Small Q wave in lead III
Inverted T wave in lead III

QT too long / too short (Qt > 1/2 RR)

Wolf-Parkinson White

HOCM

Question 6

LVH

Answer 6

Sokolov-Lyon criteria:
S wave depth in V1 + tallest R wave height in V5-V6 > 35 mm

Non-Voltage Criteria:
STE Concave limited to V1 – V3
STE is modest in relation to large voltages
STD and strain (T Wave Inversion) lateral leads (V5, V6, I, aVL)
Changes to LBBB over time
STD are downslope due to subendocardial ischemia

Precordial Leads:
R wave in V4, V5 or V6 > 26 mm

Limb Leads:
R wave in lead I + S wave in lead III > 25 mm
R wave in aVL > 11 mm
R wave in aVF > 20 mm
S wave in aVR > 14 mm

Question 7

Wolff-Parkinson-White

Answer 7

Triad of:

PR Interval <120 msec

Delta Wave (Initial Slurring of the QRS ) in at least 2/3 orthogonal leads (I, aVF, V2)

Prolonged QRS complex >110 msec

a/w:

Discordant ST and T Changes (inverted T Waves) in opposite direction of the QRS complex

MANAGEMENT:

UNSTABLE:
Synchronized cardioversion (150-200 J)

STABLE:
Vagal maneuvers
Adenosine
Procainamide: 15 to 17 mg / kg IV over 20-30 min until 50% QRS widening
DO NOT USE NODAL BLOCKING AGENTS INCLUDING BETA BLOCKERS OR CCB’S

Question 8

BIFASCICULAR BLOCK

Answer 8

RBBB plus either LAD or RAD