Syncope is probably up there with dizziness for one of my least favorite ED complaints. Our job as emergency physicians however is to triage those who had simple vasovagal episodes from those who may have significant morbidity and mortality if we just let them go home. The purpose of this blog post is to list several important things I try to look for apart from the regular obvious EKG findings that would have us worried such as an acute STEMI, SVT, V-tach. Below are several other EKG diagnoses to keep an eye out for. See if you can dx the patient prior to the answer below. 

Case 1- 25 yo male with a history of palpitations presents after syncopal episode

EKG from Life In the Fast Lane

Diagnosis

• Wolf-Parkinson-White syndrome

Pathophysiology

• Presence of a congenital accessory pathway “Bundle of Kent” which predisposes a person to deadly arrythmias. 
• Orthodromic
• Antidromic 

EKG findings

• Shortened PR interval < 120ms
• Delta Wave: Slurred begning upstroke of the QRS complex
• Wide QRS interval

 

Delta wave. Picture taken from wikiem.org

Management

• If associated with atrioventricular reentry tachycardias we need to treat
• Orthodromic conduction- Conduction from AV node back through accessory pathway
  • Narrow qrs
  • Stable Treatment- treat like SVT with Vagal maneuvers  adenosine, procainamide, calcium channel blockers 
  • Unstable treatment synchronized cardioversion
• Antidromic conduction- conduction through the accessory pathway and retrograde via SA Node
  • Wide QRS
  • Stable treatment- procainamide, amiodarone consideration
  • Unstable treatment- Synchronized cardioversion

Disposition

• Likely admission unless asymptomatic, known WPW, and cardiology can follow up very closely 

Case 2: 25 yo male with fever presents after syncopal episode

 EKG from Life in the Fast Lane

Diagnosis

• Brugada Syndrome

Pathophysiology

• Genetic sodium channelopathy with high risk for sudden cardiac death and Vfib arrest 
• Dx requires ECG findings as well as:
  • Documented ventricular fibrillation
  • Family history of sudden cardiac death
  • Similar EKG in family members
  • Syncope

EKG findings

• Right bundle branch pattern RSR’ in leads V1, V2
• ST elevation in precordial leads V1-V3
• ST elevations can have different morphology: >2mm in type 2 Brugada, > 1mm in type 3 Brugada

Management and Disposition 

• If incidental- No acute treatment but will need very close follow up for pacemaker
• If symptomatic- had syncopal episode and are now fine or active arrythmia admit with cardiology consultation for pacemaker

Case 3. 25 yo male with syncopal episode at soccer practice

Diagnosis

• Hypertrophic obstructive cardiomyopathy aka HOCM

Pathophysiology

• Genetic (1 in 500 individuals) condition which causes hypertrophy of cardiac muscles leading to possible left  ventricular outflow tract obstruction and syncope
• Decreased compliance leads to poor filling and cardiac function
• Symptoms worse with exertion typically

EKG findings

• Left ventricular hypertrophy criteria S wave in V1 + R  wave in V5 > 35mm
• “Dagger-like” Q waves can bee seen in anterolateral leads

Management

• Avoid exertional activities
• Needs ICD placement
• Can have surgical myomectomy performed
• Beta Blockers

Disposition

• Cardiology consultation and admission for echo and ICD evaluation

Case 4 25 yo male with syncopal episode while watching tv recently started on azithromycin

EKG from wikiem.org

Diagnosis

            Long QT syndrome (LQTS)

Pathophysiology

• Group of inherited conditions resulting in delayed ventricular repolarization

EKG findings

• Corrected QT interval QTc of >450 in men and > 460 in women
• QTc = QT /√R-R
• Can guestimate about half of the R-R interval as well

Management

• Unstable- defibrillation
• Stable
  • Stop any QT prolonging medication
  • Magnesium sulfate IV
  • Consider amiodarone

Disposition

• If symptomatic or QT > 500 consider admission

Case 5. 25 yo male presents s/p sudden cardiac arrest with ROSC after defibrillation 

EKG from Life in the Fast Lane

Diagnosis

• Arrhythmogenic Right Ventricular dysplasia

Pathophysiology

• Inherited myocardial disease where you get fibrofatty infiltration and thinning of the RV myocardium, RV dilation, global systolic dysfunction

EKG findings

• Epsilon wave – small positive deflection at the end of the qrs (most specific finding, seen in 30% of patients) 
• Can be confused for Osborn J wave
• Prolonged S wave Upstroke (95% of patients) similar to WPW

Management

• Treat arrythmias 
• Sotalol and Amiodarone
• Urgent ICD placement

Disposition

• Admission if symptomatic
• Very close follow up if incidental finding

Summary: 

In every EKG one should take a quick glance at the wave morphology to look for signs of WPW, HOCM, ARVD, LQTS, and Brugada ( I know that’s a lot of abbreviations). I can’t say that I have found any of these yet in my syncope patients but as Dr. Thomas told me if you never look for them you will never find them. 

Extra: I found a great pictoral from ALIEM for can’t miss EKG findings that has the changes listed above and more. I have listed it below for your reference. 

Sources: Life in the Fast Lane , Wikiem.org, ALIEM