Atrial fibrillation conducted down an accessory pathway

Atrial flutter with a varying conduction ratio

Supraventricular tachycardia with rate-related aberrancy

Monomorphic ventricular tachycardia

Palpitations and breathlessness that began during a football match an hour ago

2026-08-19

The case

19-year-old man. Palpitations and breathlessness that began during a football match an hour ago

Fit and well, no regular medication. Two shorter episodes of racing heartbeat over the past year, both stopped on their own before he reached a doctor.

On arrival

HR: 205
SpO₂ (%): 97
Respiratory rate: 24
Temperature (°C): 36.8
Systolic BP (mmHg): 104
Diastolic BP (mmHg): 62

Stage 1 of 2

Kwabena Asare walked into the department with his kit bag and is now on a trolley in resus. He is talking in short sentences, cool at the fingers, and says his chest feels tight. There is no murmur and the chest is clear. This twelve-lead was recorded while a second cannula was going in.

Tracing 1 of 2 for the quiz “Palpitations and breathlessness that began during a football match an hour ago”. — Twelve-lead recorded in resus, 25 mm/s, 10 mm/mV. Open this tracing in the studio

What is this rhythm?

AAtrial flutter with a varying conduction ratio Your answer
BSupraventricular tachycardia with rate-related aberrancy Your answer
CAtrial fibrillation conducted down an accessory pathway Correct answer Your answer
DMonomorphic ventricular tachycardia Your answer

He remains alert with a systolic pressure of 104. What do you give?

AProcainamide 10 mg/kg intravenously Correct answer Your answer
BAdenosine 6 mg by rapid intravenous push Your answer
CVerapamil 5 mg intravenously Your answer
DAmiodarone 300 mg intravenously over twenty minutes Your answer

Stage 2 of 2

The anaesthetist is called and the pads go on for a synchronised shock. Before any drug is given he stops answering, and the femoral pulse cannot be felt. This is the monitor recording across those seconds.

Tracing 2 of 2 for the quiz “Palpitations and breathlessness that began during a football match an hour ago”. — Monitor strip, lead II, 25 mm/s, 10 mm/mV. Open this tracing in the studio

What does the monitor commit you to?

AAmiodarone 300 mg intravenously over twenty minutes Your answer
BRecheck the pads and leads before shocking Your answer
CSynchronised cardioversion as already planned Your answer
DUnsynchronised shock at maximum energy Correct answer Your answer

Diagnosis

Pre-excited atrial fibrillation degenerating to ventricular fibrillation

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Discussion

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