Case 13 – Fast Start
October 30, 2017
Journal Club – Exertional Rhabdomyolysis
November 7, 2017

Case 14 – Don’t Feel Well

22 yo lacrosse player comes to your office, he says he doesn’t feel well.

No history of infectious symptoms, fevers, was sitting on the bench and had a sudden feeling of light headedness and not feeling well.
PERC negative.
He states now that in your office he feels better.

PMHx:
None
Medications: None
Allergies: None

On Examination: Pulse 54
CVS s1 s2 no murmur
Resp: Auscultation clear
MSK: Nil acute

You decide to do an ECG in your office:

Question 1:  Rate
Question 2: Rhythm
Question 3:  QRS
a) – narrow or wide
b) normal or abnormal
Question 4: What is the PR interval?

You know this player well and not to be a reliable historian you send him to the emergency department for further evaluation.

When he arrives they place him on a cardiac monitor and this is the tracing?


What is happening in the tracing?

What is the diagnosis?

 

Answers:
Question 1:  Rate – 70
Question 2: Rhythm – Normal Sinus with occasional PVC
Question 3:  QRS
a) – narrow or wide  – narrow
b) normal or abnormal – abnormal – delta waves can be seen in II, aVF, V4-V6
Question 4: What is the PR interval? It is shortened, the PR =108
Question 5: This is where the rhythm turns into a tachydysrhythmia.  A ventricular tachycardia is seen.
Question 6:  This is Wolf Parkinson White, it is associated with shortened PR intervals (less than 120) and delta waves (decreased slopes leading into R waves after shortened PR waves). Individuals with WPW are at risk of tachydysrhythmias mainly SVT and atrioventricular reentry tachycardias.   It is recommended that athletes with WPW especially if symptomatic be evaluated by a cardiologist and potentially have electrophysiological studies prior to decision about fitness to play.  Cardiac ablation may also be considered as a treatment that could allow return to sport.

Dr.  Neil Dilworth (Oct, 2017)

References:

https://www.hrsonline.org/content/download/1430/20087/file/2012-PACES-HRS%20Asymptomatic%20WPW.pdf

https://www.sads.org/images/stories/exercise/bethesda05.pdf