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Old 02-04-2019, 08:17   #16
PedOncoDoc
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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.
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Old 02-04-2019, 09:35   #17
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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??
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Old 02-04-2019, 14:34   #18
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1. Torsades de pointes
2. Magnesium
3. QTc prolonging meds and conditions
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Old 02-04-2019, 18:45   #19
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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?"
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Old 02-04-2019, 20:18   #20
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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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Old 02-05-2019, 12:10   #21
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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?
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Old 02-07-2019, 16:55   #22
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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"
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