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Treatment of torsade de pointes includes: isoproterenol infusion, cardiac pacing, and intravenous atropine. Intravenous magnesium sulfate, a relatively new mode of therapy for torsade de pointes, was proven to be extremely effective and is now regarded as the treatment of choice for this arrhythmia.
What is the treatment for torsade de pointes?
Aug 11, 2021 · Intravenous magnesium is the first-line pharmacologic therapy in Torsades de Pointes. Magnesium has been shown to stabilize the cardiac membrane, though the exact mechanism is unknown. The recommended initial dose of magnesium is a slow 2 g IV push. An infusion of 1 gm to 4 gm/hr should be started to keep the magnesium levels greater than 2 …
What is torsades de pointes?
Jan 15, 2018 · If torsades de pointes is found to have an underlying medical cause, this will be treated first. If a medication is causing the condition, a doctor may recommend an alternative treatment. For...
Can isoproterenol prevent torsades de pointes?
Torsades de Pointes is a specific type of ventricular tachycardia, or fast heart rhythm that begins in your heart ventricles. You can get it if you inherited Long QT syndrome or if you take certain medicines. Although Torsades de Pointes can be deadly if untreated, treatment greatly improves your outlook. Appointments 800.659.7822.
What medications cause torsades de pointes?
Nov 22, 2021 · Lidocaine is the preferred anti-arrhythmic drug for torsades, although there isn't a ton of evidence supporting its use. Do not use amiodarone, procainamide, beta-blockers, or most other antiarrhythmics. Most of these will stretch out the QT interval even further! Beta-blockers will slow down the heart rate, increasing the risk of torsades.
What is the treatment for torsades de pointes?
Intravenous magnesium is the first-line pharmacologic therapy in Torsades de Pointes. Magnesium has been shown to stabilize the cardiac membrane, though the exact mechanism is unknown. The recommended initial dose of magnesium is a slow 2 g IV push.Aug 11, 2021
Which drug is associated with torsades de pointes?
Antiarrhythmic drugs associated with torsade include the following: Class IA - Quinidine, disopyramide, procainamide. Class III - Sotalol, amiodarone (rare), ibutilide, dofetilide, almokalant.Jan 31, 2017
Do you Cardiovert or defibrillate torsades?
Treat the ventricular tachycardia Torsades de pointes is a ventricular tachycardia. In the unstable patient, cardiovert. In the pulseless, defibrillate. (The polymorphic nature of the rhythm may interfere with the defibrillator's ability to synchronize, so cardioversion may not be possible.Jan 9, 2017
What is treated with immediate CPR and epinephrine?
Abstract. Purpose of review: Epinephrine is the primary drug administered during cardiopulmonary resuscitation (CPR) to reverse cardiac arrest. Epinephrine increases arterial blood pressure and coronary perfusion during CPR via alpha-1-adrenoceptor agonist effects.
What are QT drugs?
The most potent QT prolonging drugs that are known to cause TdP, somewhat paradoxically, are two classes of the antiarrhythmic drugs: the Ia class (e.g. quinidine and procainamide) and the drugs in class III (e.g. dofetilide, ibutilide, sotalol and amiodarone).Sep 28, 2019
What kind of drug is adenosine?
An injectable form of adenosine is a US FDA-approved prescription drug for a condition involving rapid heart rate (paroxysmal supraventricular tachycardia). It is also used as a prescription drug to help measure blockages in the arteries of the heart.
Will AED shock torsades?
Conclusion: Lay-rescuer AEDs and professional hospital defibrillators tested in AED mode did not reliably recommend a shock for sustained monomorphic VT or TdP at certain rates, despite the fact that it is a critical component of the currently recommended treatment.
Does amiodarone cause Torsades de Pointes?
4 Amiodarone is presumed to have a low incidence of drug-induced torsades de pointes (TdP) with an incidence of <0.5%.Jun 3, 2017
Why is magnesium used for torsades de pointes?
Magnesium sulphate suppresses torsade by decreasing the influx of calcium ions, which in turn results in decreased amplitude of EADs. The initial dose is 2 g (20 ml of 10% solution), given intravenously over one to two minutes.
When do you give atropine vs epinephrine?
Epinephrine provides a greater amount of hemodynamic support. Patients dying with bradycardia aren't truly dying from bradycardia itself, but rather from cardiogenic shock (low cardiac output). Atropine offers these patients an increased heart rate, nothing more.Feb 13, 2017
When do you give epinephrine during CPR?
The recommended dose of epinephrine hydrochloride is 1.0 mg (10 mL of a 1:10 000 solution) administered IV every 3 to 5 minutes during resuscitation. Each dose given by peripheral injection should be followed by a 20-mL flush of IV fluid to ensure delivery of the drug into the central compartment.
When do you give amiodarone?
For cardiac arrest, amiodarone is used after the third shock for ventricular fibrillation and ventricular tachycardia that is unresponsive to shock delivery, CPR, and vasopressors. For tachycardia with a pulse, amiodarone may be considered, and expert consultation should be obtained prior to its use.
What is Torsades de Pointes?
Torsades de Pointes is a type of polymorphic ventricular tachycardia characterized by a gradual change in amplitude and twisting of the QRS complexes around an isoelectric line on the electrocardiogram.
Can you use overdrive pacing for torsades de pointes?
There are limited studies on the success of pacing for treatment of Torsades de Pointes; however, there are numerous case reports that show it is a viable option. Overdrive pacing can be used in the setting of both frequent runs of torsades and Torsades de Pointes that is refractory to magnesium.
Is torsade de pointes hypotensive?
Today one needs to be aware that drug-induced long QT syndrome is common and hence, a thorough medication history must be obtained. Patients with torsade may be hypotensive, have a rapid pulse and have loss of consciousness. Evaluation. An electrocardiogram is paramount in the diagnosis of Torsades de Pointes.
Is Torsades de Pointes asymptomatic?
Around 50% of patients with Torsades de Pointes are asymptomatic. The most common symptoms reported are syncope, palpitations, and dizziness. However, cardiac death is the presenting symptom in up to 10% of patients. Patients with Jervell and Lange Nielsen syndrome may have a history of deafness.
Does isoproterenol help with TDP?
Isoproterenol has been shown to help prevent Torsades de Pointes in patients with prolonged QT that is refractory to magnesium. It is a non-selective beta agonist, which increases the heart rate and shortens the QT interval. This lowers the likelihood of an R-on-T phenomenon that can lead to TdP.
What is the name of the heart that beats faster than the atria?
Torsades de pointes is French for “twisting of points” and refers to when the heart’s two lower chambers or ventricles, beat faster than the upper chambers, which are known as the atria. Most cases of torsades de pointes resolve on their own without treatment.
What is a torsades de pointes?
Torsades de pointes is a form of tachycardia that shows up as a ribbon-like EKG pattern. Problems that occur with the heart’s rhythm are known as arrhythmias. When the heart beats faster than usual, as in a case of torsades de pointes, it is called tachycardia. Torsades de pointes is French for “twisting of points” and refers to when ...
What causes sudden and uncontrollable changes in a person's heart rate in response to stress or exercise?
LQTS causes sudden and uncontrollable changes or arrhythmias in a person’s heart rate in response to stress or exercise. These arrhythmias can be very dangerous. There is also a range of conditions and medications that cause or influence the development of torsades de pointes. These include:
What medications cause torsades de pointes?
There is also a range of conditions and medications that cause or influence the development of torsades de pointes. These include: 1 antiarrhythmic drugs, including quinidine, procainamide, and disopyramide 2 antipsychotics or tricyclic antidepressants 3 methadone, erythromycin, and ketoconazole 4 intracranial bleeding, or bleeding inside the skull 5 electrolyte disturbances, such as hypokalemia, hypomagnesemia, and hypocalcemia 6 acute myocardial infarction, or a blockage in a coronary artery 7 kidney injury 8 liver failure 9 toxins from heavy metals or insecticides 10 anorexia 11 malnutrition
What is the shape of a wavy line on an EKG?
In cases of torsades de pointes, these lines will form a distinctive shape, much like a party ribbon that has been twisted.
What is an EKG?
Image credit: CardioNetworks, (2010, April 10) An EKG measures the electrical activity of the heart. Electrical signals control the heart, starting at the top in the atria, and working their way down into the ventricles. This process makes the heart pump blood around the body.
What is the treatment for LQTS?
For people with a congenital form of LQTS, treatment includes: beta-adrenergic antagonists, such as propranolol. beta-blockers. pacemakers. implantable cardioverter defibrillator in rare cases. For people with acquired torsades de pointes, specific treatment is not usually needed.
Overview
Torsades de Pointes is a type of very fast heart rhythm (tachycardia) that starts in your heart’s lower chambers (ventricles). Unlike a normal pulse rate of 60 to 100 beats a minute, a fast heartbeat in your ventricles ( ventricular tachycardia) is more than 100 beats a minute.
Symptoms and Causes
Half of the people with Torsades de Pointes don’t have any symptoms. People who get symptoms can experience:
Diagnosis and Tests
Your provider can see a distinct pattern that looks like twisting points or peaks (which it means in French) on an electrocardiogram (EKG).
Management and Treatment
You will stay in the hospital until your unusual heart rhythm is under control. Your provider may stop giving you medicines that could cause Torsades de Pointes and use other medicines and/or medical devices to help you.
Living With
There are several things you should do to take care of yourself with Torsades de Pointes.
Frequently Asked Questions
Torsades de Pointes can be dangerous if it’s not treated. But your outlook is good if you follow your provider’s instructions and keep your follow-up appointments. Getting basic life support training for your family may give you peace of mind in case you need help.
What medications cause TDP?
Knowledge that TdP may occur in patients taking certain prescription drugs has been both a major liability and reason for removal of 14 medications from the marketplace. Forty nine drugs known to cause TdP and another 170 that are known to prolong QTc remain on the market because the drugs provide medical benefit and the risk of TdP can be managed and mitigated by instructions in the drug label. Examples of compounds linked to clinical observations of TdP include amiodarone, most fluoroquinolones, methadone, lithium, chloroquine, erythromycin, azithromycin, pimozide, and phenothiazines. The anti-emetic agent ondansetron may also increase the risk of developing TdP. It has also been shown as a side effect of certain anti-arrhythmic medications, such as sotalol, procainamide, quinidine, ibutilide, and dofetilide In one example, the gastrokinetic drug cisapride (Propulsid) was withdrawn from the US market in 2000 after it was linked to deaths caused by long QT syndrome-induced torsades de pointes. This effect can be directly linked to QT prolongation mediated predominantly by inhibition of the hERG channel and, in some cases, augmentation of the late sodium channel.
What is a TDP?
Torsades de pointes, torsade de pointes or torsades des pointes ( TdP) ( / tɔːˌsɑːd də ˈpwæ̃t /, French: [tɔʁsad də pwɛ̃t̪], translated as "twisting of peaks") is a specific type of abnormal heart rhythm that can lead to sudden cardiac death. It is a polymorphic ventricular tachycardia that exhibits distinct characteristics on ...
What drugs can cause torsades de pointes?
Certain drugs and combinations of drugs resulting in drug interactions are common contributors to torsades de pointes risk. QT-prolonging medications such as clarithromycin, levofloxacin, or haloperidol, when taken concurrently with cytochrome P450 inhibitors, such as fluoxetine, cimetidine, or particular foods including grapefruit, ...
Why do Torsades occur?
Torsades occurs as both an inherited (linked to at least 17 genes) and as an acquired form caused most often by drugs and/or electrolyte disorders that cause excessive lengthening of the QT interval.
How to prevent torsades?
Treatment to prevent recurrent torsades includes infusion of magnesium sulphate, correction of electrolyte imbalances such as low blood potassium levels ( hypokalaemia ), and withdrawal of any medications that prolong the QT interval.
What are some examples of TDP?
Examples of compounds linked to clinical observations of TdP include amiodarone, most fluoroquinolones, methadone, lithium, chloroquine, erythromycin, azithromycin, pimozide, and phenothiazines. The anti-emetic agent ondansetron may also increase the risk of developing TdP.
What happens if you prolong your QT?
Prolongation of the QT interval can increase a person's risk of developing this abnormal heart rhythm, occurring in between 1% and 10% of patients who receive QT-prolonging antiarrhythmic drugs.
What is a torsade de pointes?
Torsades de Pointes. Torsades is defined as the combination of polymorphic ventricular tachycardia plus a prolonged QT-interval. Torsades can be caused by either congenital long-QT syndrome or acquired long-QT syndrome (due to electrolyte abnormalities and/or medications). The vast majority of torsades results from acquired long-QT syndrome, ...
What is polymorphic ventricular tachycardia?
Polymorphic ventricular tachycardia. Defined as ventricular tachycardia with varying QRS amplitude. This is commonly referred to as torsades de pointes, but it's actually not the same thing. Polymorphic ventricular tachycardia may be caused by several etiologies (e.g. congenital QT prolongation, acquired QT prolongation, ischemia, ...
What is recurrent torsade?
Recurrent torsades may reflects inadequate magnesium dosing (e.g. patient is bolused with 2-4 grams, without an infusion). The first step when managing recurrent torsades is therefore to ensure that the patient has truly received an adequate dose of magnesium.
What happens if you break torsades?
If the EKG shows a prolonged QT-interval, the patient is diagnosed with torsades. If you simply break torsades but do nothing else, it is likely to recur. The following therapies will prevent recurrence of ventricular tachycardia in this situation:
Can magnesium cause tachycardia?
giving two-four grams magnesium and walking away). This will often cause recurrence of ventricular tachycardia in a few hours after the serum magnesium levels fall. Leaving patients on QT-prolonging meds (make sure to scour the medication list for any problematic drugs).
What is the best antiarrhythmic for torsades?
lidocaine. Lidocaine is the preferred anti-arrhythmic drug for torsades, although there isn't a ton of evidence supporting its use. Do not use amiodarone, procainamide, beta-blockers, or most other antiarrhythmics. Most of these will stretch out the QT interval even further!
Is Torsades easy to control?
Torsades is generally fairly easy to control with a combination of high-dose magnesium, heart rate augmentation, and occasionally some lidocaine. Failure to respond to these interventions suggests an alternative diagnosis (e.g. polymorphic VT due to ischemia or catecholaminergic ventricular tachycardia).
What causes PVT in the heart?
The most common cause of PVT is myocardial ischaemia/infarction. Torsades de pointes (TdP) is a specific form of PVT occurring in the context of QT prolongation — it has a characteristic morphology in which the QRS complexes “twist” around the isoelectric line. Torsades de pointes. For TdP to be diagnosed, the patient must have evidence ...
What is the term for a PVC that occurs during the preceding T wave?
EADs may manifest on the ECG as tall U waves; if these reach threshold amplitude they may manifest as premature ventricular contractions (PVCs) TdP is initiated when a PVC occurs during the preceding T wave, known as ‘R on T’ phenomenon.
What is bidirectional VT?
Bidirectional VT is another specific type of of PVT, most commonly associated with digoxin toxicity.
Can TDP cause VF?
TdP may also degenerate into ventricular fibrillation (VF) QT prolongation may occur secondary to multiple drug effects, electrolyte abnormalities and medical conditions; these may combine to produce TdP, e.g. hypokalaemia may precipitate TdP in a patient with congenital long QT syndrome.
What is the treatment for ventricular fibrillation?
The answer is D. Ventricular fibrillation is primarily treated with defibrillation. If three successive shocks and epinephrine have been given, the next line agent would be an antiarrhythmic, such as lidocaine or amiodarone.
Why is chin lift dangerous?
The chin-lift maneuver risks spinal injury due to its employment of neck extension. The answer is E. In many patients in the Emergency Department, the inability to rule-out cervical spine injury negates the option to use the chin-lift maneuver, since this method of airway opening can exacerbate C-spine injury.
Overview
Treatment
The treatment of torsades de pointes aims to restore a normal rhythm and to prevent the arrhythmia recurring. While torsades may spontaneously revert to a normal sinus rhythm, sustained torsades requires emergency treatment to prevent cardiac arrest. The most effective treatment to terminate torsades is an electrical cardioversion- a procedure in which an electrical current is applied across the heart to temporarily stop and then resynchronise the heart's cells. T…
Signs and symptoms
Most episodes will revert spontaneously to a normal sinus rhythm. Symptoms and consequences include palpitations, dizziness, lightheadedness (during shorter episodes), fainting (during longer episodes), and sudden cardiac death.
Causes
Torsades occurs as both an inherited (linked to at least 17 genes) and as an acquired form caused most often by drugs and/or electrolyte disorders that cause excessive lengthening of the QT interval.
Common causes for torsades de pointes include drug-induced QT prolongation and less often diarrhea, low serum magnesium, and low serum potassiumor congenital long QT syndrome. It ca…
Risk factors
The following is a partial list of factors associated with an increased tendency towards developing torsades de pointes:
• Medications
• Hypokalemia (low serum potassium)
• Hypomagnesemia (low serum magnesium)
Pathophysiology
Action potential of cardiac muscles can be broken down into five phases:
• Phase 0: Sodium channels open, resulting in the entrance of Na into the cells; this results in the depolarization of the cardiac muscles.
• Phase 1: Sodium channels close; this stops depolarization. Potassium channels open, leading to an outward current of K out of the cells.
Diagnosis
The ECG tracing in torsades demonstrates a polymorphic ventricular tachycardia with a characteristic illusion of a twisting of the QRS complex around the isoelectric baseline (peaks, which are at first pointing up, appear to be pointing down for subsequent "beats" when looking at ECG traces of the "heartbeat"). It is hemodynamically unstable and causes a sudden drop in arterial blood pressure, leading to dizziness and fainting. Depending on their cause, most individ…
R-on-T phenomenon
The R-on-T phenomenon is the superimposition of a premature ventricular contraction on the T wave of a preceding heart beat. Studies suggest that R-on-T phenomenon is likely to start a sustained ventricular tachycardia and ventricular fibrillation. It's considered a cardiac arrhythmia in which the ventricles of the heart become again excited during the repolarization of the previous heart action. Because part of the heart muscle cannot be excited at this early point in time, a pre…