51yo Male w/ Nasal Congestion

51 yo male w/ no PMH presents w/ nasal congestion. Went to local outpatient care station for cough & congestion x 4-5 days. afebrile. Care station VS showed HR in 180's, sent to ED. No CP/SOB/Syncope/Dizziness/Palpitations. Patient had no history of arrhythmia. BP 130/78. Unremarkable physical exam.


EKG showed a Wide, Regular Tachycardia, and the patient had a normal SBP and was essentially asymptomatic so this patient was considered "stable".  Differential includes Vtach vs SVT w/ abberancy.  Treatment options include Adenosine, Procainamide, Amiodarone, electricity (Adenosine should/can only be used in wide complex tachycardias that are regular).  If the patient was unstable, electricity would have been the first choice.  No one will fault you for treating all wide/regular tachycardias as VT, but the treatment of choice for stable VT is up for debate.  It is not recommended to use both Amiodarone AND Procainamide because their side effects can be additive, so pick one and stick with it.  Our patient got Amiodarone, which did had no significant effect. The patient then got 6mg Adenosine, which had no effect.  12mg of Adenosine then converted our patient into the EKG below.


WPW. 51 yo and had never been diagnosed. Son of a bee sting. His accessory pathyway was ablated 2 days later and was discharged without further complication.

If I could do it again, I would have started with Adenosine, then Procainamide would have been my 2nd choice, and I would have used electricity if those had both failed.