lha
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A 69-year-old woman with a history of severe coronary artery disease and a permanent pacemaker for tachybrady syndrome is admitted for dyspnea secondary to congestive heart failure. Her medications include digoxin, amiodarone, metoprolol, and furosemide. While in the telemetry unit, she develops torsades de pointes. She is initially treated with magnesium, atropine, and potassium. Her resting heart rate now is in the 40s. However, she continues having intermittent runs of torsade. The QT interval is 610 milliseconds. What is the next step in treating this dysrhythmia?
(A) Increase the atrial rate of the pacemaker
(B) Isoproterenol
(C) Procainamide
(D) Change oral amiodarone to intravenous
(E) Defibrillation at 200 Joules (J)
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| reliable_26
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Hi..
this is really good..q..but very high end..
If TdP recurs..the treament is ICD...
Where did u get tis q from..
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| msyamp
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A increase the rate of atrial pace maker.Pacing at rates up to 140 bpm may prevent the ventricular pauses that allow TDP to originate.
Even Isoproterenol and Defib works. But i will first try to do it with increasing the firing
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| Jinx
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a
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| ladybug
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E.
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| AAAAA
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The older version of the pacemaker is placed on the left side of the right ventricle and how are you going to regulate the atrial rate?
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| guayoman
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I guess if the option says atrial rate it is an atrial/ventricular pacemaker? It is synchronized, and now they want to increase the atrial half? but that could turn it into WPW right !? I never heard of such thing...I'm just thinking out loud because of the pathophysiology of both deases.
Remember that cardioversion and isoproterenol are used when hemodinamically unstable.
Edited by guayoman on 05/24/06 - 11:01 PM
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| guayoman
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Please explain answer Iha
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| guayoman
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don't let this post die!
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| karusmle
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answer plzzzzzzzzzzzzzz
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| AAAAA
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Treatment of Torsades de Pointes:
Prehospital Care:
- Institute immediate advanced cardiac life support (ACLS) protocol for VT.
- Overdrive pacing may be necessary at a rate of up to 140 bpm to control the rhythm.
Emergency Department Care: Torsade, an inherently unstable rhythm, is prone to revert to more stable rhythms spontaneously and prone to recurrences. Torsade also is subject to degeneration into ventricular fibrillation. Begin therapy as soon as the rhythm clearly fulfills the criteria for torsade. - Treat hypokalemia if it is the precipitating factor and administer magnesium sulfate in a dose of 2-4 g intravenously (IV) initially.
- Magnesium is usually very effective, even in the patient with a normal magnesium level.
- If this fails, repeat the initial dose, but because of the danger of hypermagnesemia (depression of neuromuscular function) the patient requires close monitoring.
- Other therapies include overdrive pacing and isoproterenol infusion. Most (75-82%) torsade de pointes (TDP) rhythms are started by a pause. Pacing at rates up to 140 bpm may prevent the ventricular pauses that allow TDP to originate.
- The patient with torsade who is in extremis should be treated with electrical cardioversion or defibrillation. Anecdotal reports cite successful conversion with phenytoin (Dilantin) and lidocaine.
- Patients with congenital long QT syndromes are thought to have an abnormality of sympathetic balance or tone and are treated with beta-blockers. If the patient breaks through this therapy and enters the ED in torsade, a short-acting beta-blocker, such as esmolol, can be tried.
- A few cases of successful conversion using phenytoin and overdrive pacing have been reported.
If patient is unresponsive to conversion with phenytoin and overdrive pacing, attempt electrical cardioversion. - Cervical sympathectomy and implantable pacemakers/defibrillators have been used in some cases for long-term management.
- Shortening the action potential decreases the likelihood of immediate recurrence. Pacing or administration of isoproterenol to a rate of 90-100 bpm is effective.
- Withdraw all QT-prolonging drugs.
Consultations: Immediate cardiology evaluation and follow-up are required.
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| AAAAA
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The answer is A. Increase the pacing to 140 and ablate the origin of Torsades de pointes and its reoccurence.
This question asks you how to treat refractory recurrent Torsades de pointes.
The correct answer is increase the pacing beyong 140bpm.
Thanks for allowing me to participate !
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| AAAAA
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So it is pacing UP to 140 bpm!
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| AAAAA
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EKG
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0703967f4.jpg (107 KB, 6 downloads)
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