Go Back   Professional Soldiers ® > TMC 14 > Medical Pearls Of Wisdom

Reply
 
Thread Tools Display Modes
Old 02-04-2019, 08:17   #16
PedOncoDoc
Area Commander
 
PedOncoDoc's Avatar
 
Join Date: Oct 2009
Location: Northeast Utah
Posts: 1,712
Definitely looks like pulseless ventricular tachycardia.

We've just gone way past the comfort level of this pediatric stem cell transplant and cellular therapy specialist - I'm bowing out of the management, but watching closely and learning.
__________________
‎"The dignity of man is not shattered in a single blow, but slowly softened, bent, and eventually neutered. Men are seldom forced to act, but are constantly restrained from acting. Such power does not destroy outright, but prevents genuine existence. It does not tyrannize immediately, but it dampens, weakens, and ultimately suffocates, until the entire population is reduced to nothing better than a flock of timid, uninspired animals, of which the government is shepherd." - Alexis de Tocqueville
PedOncoDoc is offline   Reply With Quote
Old 02-04-2019, 09:35   #17
Trapper John
Quiet Professional
 
Trapper John's Avatar
 
Join Date: Nov 2012
Location: Harrisburg, PA
Posts: 3,834
Quote:
Originally Posted by PedOncoDoc View Post
Definitely looks like pulseless ventricular tachycardia.

We've just gone way past the comfort level of this pediatric stem cell transplant and cellular therapy specialist - I'm bowing out of the management, but watching closely and learning.
I am with you Doc! This is an excellent case study and I expect to learn a lot.

Still curious about the possibility of pulmonary hypertension/embolism as a contributing factor??
__________________
Honor Above All Else
Trapper John is offline   Reply With Quote
Old 02-04-2019, 14:34   #18
olddoc
Asset
 
Join Date: Jun 2008
Location: MS
Posts: 28
1. Torsades de pointes
2. Magnesium
3. QTc prolonging meds and conditions
olddoc is offline   Reply With Quote
Old 02-04-2019, 18:45   #19
ender18d
Quiet Professional
 
ender18d's Avatar
 
Join Date: May 2004
Location: Pineland
Posts: 168
Quote:
Originally Posted by olddoc View Post
1. Torsades de pointes
2. Magnesium
3. QTc prolonging meds and conditions

Not all ventricular tachycardia is created equal. Olddoc has identified that this is Torsades de Pointes, a form of polymorphic ventricular tachycardia associated with prolonged QT syndrome. Its worth remembering that not all polymorphic VT is Torsades and polymorphic VT can be caused by coronary ischemia, but in this case you feel very comfortable diagnosing Torsades given the morphology of the tracing and the fact that the patient came in with a QTc of 652.

So you give magnesium, confident that in every ACLS training you've ever done Torsades patients get better immediately when magnesium is administered. You start preparing for your victory lap around the emergency department when one of the nurses nudges you and says:

"hey Doc, he's still in pulseless Torsades. What do we do now?"
__________________
Medicina Bona Locis Malis
ender18d is offline   Reply With Quote
Old 02-04-2019, 20:18   #20
Shrub
Asset
 
Join Date: May 2018
Location: Rhode Island
Posts: 4
Treatment of Torsades de Pointes is IV atropine, defibrillation. I'm not sure if there will be a need for pacing.
Shrub is offline   Reply With Quote
Old 02-05-2019, 12:10   #21
ender18d
Quiet Professional
 
ender18d's Avatar
 
Join Date: May 2004
Location: Pineland
Posts: 168
Quote:
Originally Posted by Shrub View Post
Treatment of Torsades de Pointes is IV atropine, defibrillation. I'm not sure if there will be a need for pacing.
I think some clarification is in order but really good and interesting ideas here.

1. The treatment for unstable ventricular tachycardia of any kind is defibrillation. We always talk about magnesium for Torsades and it is generally a very effective treatment, but if they are in cardiac arrest or grossly unstable they need electricity. So this is first. If they are in arrest don't delay a shock waiting for Mag.

2. Pacing is actually a REALLY interesting idea and one that I was not smart enough to think of when I ran this case. Torsades results from long QT, and long QT is exacerbated by bradycardia. Chronotropy, either electrical or chemical can reportedly shorten up the QT and pull someone out of Torsades. With electricity, we refer to this as "overdrive" pacing.

3. Atropine is more controversial. As above, the theory is that you can use it to shorten up the QT, although its not well studied and if available people usually talk about isoproterenol for this application. This is something suggested in various corners of the literature but not 100% accepted.

4. Consider lidocaine. Avoid amiodarone and other QT prolonging agents. Lidocaine was mentioned earlier in this thread and its my first choice anti-arrhythmic for Torsades.

5. Consider a Mag infusion. ACLS calls for 1-2MG of Mag, but consider redosing and then hanging a drip. Its sort of like a Narcan thing: the long QT can outlast the Mag.


I'll call index on this case here. Hope y'all enjoyed it!

The post-script is I coded this guy for about ~45 minutes and the Mag was just not doing it. When we finally got labs his K+ was about 2.0 which was an exacerbating factor. We threw the kitchen sink at him, shocked him frequently. At the time I'd never heard of overdriving someone out of Torsades, so did not try that. I think in the end it was either the Lidocaine, starting the K replacement, or Calcium that finally got him to convert and stay converted.

Amazingly, despite 45min of compressions and shocks, he started waking up literally minutes after he converted and following commands shortly thereafter. He was pulled off all his QT prolonging meds and his K was replaced and he did well. Cathed later by cards with nothing acute. He has no lasting deficits and is applying to go back to grad school.

Learning points:
-Having an early differential can help you in a code situation
-Lots of interesting features to his presenting ECG
-Not all Ventricular tachycardia is created equal
-You need to know more about Torsades than just "give it mag and it gets better."


Questions?
__________________
Medicina Bona Locis Malis
ender18d is offline   Reply With Quote
Old 02-07-2019, 16:55   #22
Trapper John
Quiet Professional
 
Trapper John's Avatar
 
Join Date: Nov 2012
Location: Harrisburg, PA
Posts: 3,834
I can see why he liked this case study so much. Truly is an excellent teaching case and thank you so much for posting this and leading the discussion. " Finest Kind"
__________________
Honor Above All Else
Trapper John is offline   Reply With Quote
Old 02-23-2019, 14:47   #23
ender18d
Quiet Professional
 
ender18d's Avatar
 
Join Date: May 2004
Location: Pineland
Posts: 168
Quote:
Originally Posted by Trapper John View Post
I can see why he liked this case study so much. Truly is an excellent teaching case and thank you so much for posting this and leading the discussion. " Finest Kind"
Cheers brother!

I wonder if anyone would be interested in doing ultrasound cases. I'm a bit of an ultrasound nerd, and now that 18Ds are getting trained on this, I'd love to get more training out there. I save all my most interesting clips from good cases.
__________________
Medicina Bona Locis Malis
ender18d is offline   Reply With Quote
Old 02-23-2019, 18:19   #24
Trapper John
Quiet Professional
 
Trapper John's Avatar
 
Join Date: Nov 2012
Location: Harrisburg, PA
Posts: 3,834
Quote:
Originally Posted by ender18d View Post
Cheers brother!

I wonder if anyone would be interested in doing ultrasound cases. I'm a bit of an ultrasound nerd, and now that 18Ds are getting trained on this, I'd love to get more training out there. I save all my most interesting clips from good cases.
Give it a shot brother.

I am always up for learning something new especially with blurry pictures.
__________________
Honor Above All Else
Trapper John is offline   Reply With Quote
Reply


Currently Active Users Viewing This Thread: 1 (0 members and 1 guests)
 
Thread Tools
Display Modes

Posting Rules
You may not post new threads
You may not post replies
You may not post attachments
You may not edit your posts

BB code is On
Smilies are On
[IMG] code is Off
HTML code is Off

Forum Jump



All times are GMT -6. The time now is 15:17.



Copyright 2004-2022 by Professional Soldiers ®
Site Designed, Maintained, & Hosted by Hilliker Technologies