kind of a trick

Sometimes life isn’t logical. Little bits of irony or surprises can throw a person off. Sometimes those surprises are pleasant, like a flower in the snow…

Skunk Cabbage “flowers” actually perform some sort of exothermic chemical reaction that allows them to melt their way out of the ground

Other times we can get thrown off when things aren’t necessarily what we expect. Take this patient…

~40 y.o. woman with painful cough

Full disclosure, she doesn’t actually have a cough. But if she did have a cough, her EKG would look the same way…

Rate looks to be mid or upper 90’s, rhythm is sinus with a PVC. Axis is normal. The P wave in V1 looks to be inverted so she may have some LAE. The QRS looks a little off. Many of you questioned a partial RBBB since there is a sense of an RSR’ in V1. The QRS honestly looks a little wide in II and V5, let’s zoom in on the lead II rhythm strip.

While the QRS looks somewhat wide, there’s basically no PR interval, the QRS comes right off the PR. A short PR means you have think about an accessory pathway and WPW. Some of you noticed the Q wave in aVL, I bet a smart electrophys specialist could tell us a lot about where the accessory pathway is based on that downward deflection. There is some TWI or STD to the lateral chest leads, almost as if the patient had just had experienced a bout of tachycardia and was showing a bit of a strain pattern…

This is actually the EKG of last week’s WPW patient after the dysrhythmia had resolved. I included it mostly just to show how subtle the delta waves can be; I think these would be really really difficult to definitively call prospectively … though in retrospect the short PR interval (a place on the EKG we often don’t look) is certainly supportive.