Torsades de pointes: Difference between revisions
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==Background== | ==Background== | ||
*Form of polymorphic [[VTach]] | |||
**Gradual change in the amplitude of QRS complexes and twisting around isoelectric line | |||
*Associated with congenital or acquired [[prolonged QT]] | |||
* | ===Common Causes=== | ||
* | '''POINTES''' mnemonic: | ||
* | *[[Phenothiazines|'''P'''henothiazines]] | ||
* | *'''O'''ther medications (ie [[TCAs]]) | ||
*[[ICH|'''I'''ntracranial bleed]] | |||
*'''N'''o known cause (idiopathic) | |||
*'''T'''ype I [[antiarrhythmics]] ([[quinidine]], [[procainamide]], disopyramide) | |||
*[[electrolyte Abnormality|'''E'''lectrolyte abnormalities]] ([[hypokalemia|hypoK]] & [[hypomagnesemia|hypoMg]]) | |||
*'''S'''yndrome of [[Prolonged QT]] (aka Long QT Syndrome) | |||
*Other causes: | |||
**[[Organophosphate toxicity]] | |||
**[[Hydrocarbon toxicity]] | |||
**[[Chloral hydrate toxicity]] | |||
**[[Hypothermia]] | |||
== | ==Clinical Features== | ||
#Magnesium | *[[Syncope]] | ||
# | *[[Dizziness]], lightheadedness | ||
#Overdrive pacing | *[[Palpitations]] | ||
# | *Sudden [[cardiac arrest]] | ||
# | |||
## | ==Differential Diagnosis== | ||
*Drug induced | |||
*Congenital long QT | |||
*[[Hypocalcemia]] | |||
*[[Hypomagnesemia]] | |||
*[[Hypokalemia]] | |||
*[[Hypothermia]] | |||
*POINTES as above | |||
{{Tachycardia (wide) DDX}} | |||
==Evaluation== | |||
===Workup=== | |||
*[[ECG]] | |||
*BMP, Mg, Phos | |||
===Diagnosis=== | |||
[[File:12leadTorsade.jpg|thumb|Classic torsades in 12-lead]] | |||
[[File:Torsades de Pointes TdP.png|thumb|Torsades de Pointes (TdP) in patient with a potassium of 2.4 mmol/L and a magnesium of 1.6mg/dL.]] | |||
*[[ECG]] showing the QRS complexes “twisting” around the isoelectric line | |||
==Management== | |||
Increasing HR decreases QT interval | |||
#[[Magnesium sulfate]] - decreases calcium influx | |||
#*1-2gm IV over 1-2 min, repeat in 5-15min; then 1-2gm/hr (3-10mg/min) drip | |||
#**Danger of [[hypermagnesemia]] → depressed neuromuscular function and respiratory drive, so monitor closely | |||
#**Supplement with K+ | |||
#[[Isoproterenol]] - Increases HR / AV conduction | |||
#*2-8 mcg/min | |||
#*Target HR > 90 bpm | |||
#[[Overdrive Pacing]] - Atrial > Ventricular pacing | |||
#*Goal HR 90-120 | |||
#*Note: Not a treatment for TdP, but useful in maintaining sinus rhythm | |||
#[[Defibrillation]] / [[synchronized cardioversion]] - Patient in extremis | |||
#'''AVOID''' amiodarone and procainamide, which may worsen prolonged QT | |||
# Lidocaine (a class Ib antiarrhythmic drug) shortens the QT interval and may be effective especially for drug-induced torsades de pointes | |||
#*Lidocaine 1 mg/kg bolus, followed by 0.5-4 mg/min, titrated to rhythm response<ref>Reachi B, Negrelli J, Hickman A, Beesley S, Osborn J (2019) Isoproterenol and Lidocaine for Recurrent Torsades de Pointes in a 32-year-old Pregnant Woman. Int J Crit Care Emerg Med 5:092.</ref> | |||
#*Inpatient may monitor plasma lidocaine levels, with goal < 6 mcg/mL | |||
==Disposition== | |||
*Admit | |||
==See Also== | ==See Also== | ||
Line 23: | Line 71: | ||
*[[ACLS (2010 Guidelines)]] | *[[ACLS (2010 Guidelines)]] | ||
== | ==References== | ||
<references/> | |||
[[Category: | [[Category:Cardiology]] |
Revision as of 17:38, 1 July 2020
Background
- Form of polymorphic VTach
- Gradual change in the amplitude of QRS complexes and twisting around isoelectric line
- Associated with congenital or acquired prolonged QT
Common Causes
POINTES mnemonic:
- Phenothiazines
- Other medications (ie TCAs)
- Intracranial bleed
- No known cause (idiopathic)
- Type I antiarrhythmics (quinidine, procainamide, disopyramide)
- Electrolyte abnormalities (hypoK & hypoMg)
- Syndrome of Prolonged QT (aka Long QT Syndrome)
- Other causes:
Clinical Features
- Syncope
- Dizziness, lightheadedness
- Palpitations
- Sudden cardiac arrest
Differential Diagnosis
- Drug induced
- Congenital long QT
- Hypocalcemia
- Hypomagnesemia
- Hypokalemia
- Hypothermia
- POINTES as above
Wide-complex tachycardia
Assume any wide-complex tachycardia is ventricular tachycardia until proven otherwise (it is safer to incorrectly assume a ventricular dysrhythmia than supraventricular tachycardia with abberancy)
- Regular
- Monomorphic ventricular tachycardia
- PSVT with aberrant conduction:
- PSVT with bundle branch block^
- PSVT with accessory pathway
- Atrial flutter with bundle branch block^
- Sinus tachycardia with bundle branch block^
- Accelerated idioventricular rhythm (consider if less than or ~120 bpm)
- Metabolic
- Irregular
- Atrial fibrillation/atrial flutter with variable AV conduction AND bundle branch block^
- Atrial fibrillation/atrial flutter with variable AV conduction AND accessory pathway (e.g. WPW)
- Atrial fibrillation + hyperkalemia
- Polymorphic ventricular tachycardia
^Fixed or rate-related
Evaluation
Workup
- ECG
- BMP, Mg, Phos
Diagnosis
- ECG showing the QRS complexes “twisting” around the isoelectric line
Management
Increasing HR decreases QT interval
- Magnesium sulfate - decreases calcium influx
- 1-2gm IV over 1-2 min, repeat in 5-15min; then 1-2gm/hr (3-10mg/min) drip
- Danger of hypermagnesemia → depressed neuromuscular function and respiratory drive, so monitor closely
- Supplement with K+
- 1-2gm IV over 1-2 min, repeat in 5-15min; then 1-2gm/hr (3-10mg/min) drip
- Isoproterenol - Increases HR / AV conduction
- 2-8 mcg/min
- Target HR > 90 bpm
- Overdrive Pacing - Atrial > Ventricular pacing
- Goal HR 90-120
- Note: Not a treatment for TdP, but useful in maintaining sinus rhythm
- Defibrillation / synchronized cardioversion - Patient in extremis
- AVOID amiodarone and procainamide, which may worsen prolonged QT
- Lidocaine (a class Ib antiarrhythmic drug) shortens the QT interval and may be effective especially for drug-induced torsades de pointes
- Lidocaine 1 mg/kg bolus, followed by 0.5-4 mg/min, titrated to rhythm response[1]
- Inpatient may monitor plasma lidocaine levels, with goal < 6 mcg/mL
Disposition
- Admit
See Also
References
- ↑ Reachi B, Negrelli J, Hickman A, Beesley S, Osborn J (2019) Isoproterenol and Lidocaine for Recurrent Torsades de Pointes in a 32-year-old Pregnant Woman. Int J Crit Care Emerg Med 5:092.