WOBBLER for ECG assessment in Syncope W - Wolff Parkinson White O - Obstructed AV pathway B - Bifascicular block B - Brugada L - Left ventricular Hypertrophy (consider AS, HOCM) E - Epsilon wave R - Repolarisation abnormality So WOBBLER may help you find the important and rare abnormalities not to be missed in the syncope patient, going from left to right from P wave through to T wave, in the patient that does not have obvious dysrhythmia or ischaemia. W is Wolff-Parkinson-White syndrome – look for a short PR interval or delta wave O is obstructed AV pathway – look for 2nd or 3rd degree block or axis deviation …which is the first step in looking for B bifascicular block, or the combination of axis deviation and right bundle branch block the second B is Brugada, looking for characteristic morphology of the ST segment, so called coved ST elevation Now syncope, especially exertional syncope, can be caused by left ventricular outflow tract obstruction. Two conditions not to be missed associated with this (and exertional syncope) are hypertrophic cardiomyopathy and aortic stenosis. These both characteristically cause L– left ventricular hypertrophy E– stands for epsilon wave, a feature of arrythmogenic right ventricular cardiomyopathy, a rare disorder associated with sudden cardiac death. The epsilon wave looks a bit like the J wave of hypothermia and may be associated with other T wave abnormalities in V1-V3 Finally, R stands for Repolarisation abnormality, particularly delayed Repolarisation as found in long QT syndrome but remember there is also a short QT syndrome too #WOBBLER #Mnemonic #Syncope #EKG #ECG #Diagnosis #Cardiology
