Quote:
Originally Posted by Shrub
Treatment of Torsades de Pointes is IV atropine, defibrillation. I'm not sure if there will be a need for pacing.
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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?