Torsades de Pointes

Why is Torsades everyone's favorite arrhythmia? Maybe because if you see it once and you will never forget it? Because IV Magnesium can provide dramatic reversal of the arrhythmia right before your eyes? Because the algorithm is so easy to remember? Let's look at it in a little more detail.... Torsades de Pointes, translated as "twisting of the spikes," is an irregular polymorphic wide complex tachycardia typically caused by one of two things. Most commonly it is triggered from prolonged QT syndrome. Prolonged QT is exacerbated by hypokalemia and hypomagnesemia as well as many medications, including some antiarrhythmics. When a PVC takes place during the relative refractory period between the QRS wave and T wave in the EKG, ventricular tachycardias can result. In the case of Torsades, the treatment of choice is Magnesium Sulfate, 1 to 2 grams IV. Another potential cause of Torsades is ischemia. In this instance, IV Magnesium will have no effect, and the ischemia will need to be reversed. (Cath Lab!) IV Magnesium probably will do no harm, and is still the initial treatment per the algorithm. When a patient presents with Torsades, an old EKG showing a previous prolonged QT would be one way to differentiate between the potential underlying cause of the disorder.

Generally "stable" Torsades is uncommon, and the rhythm tends to deteriorate quickly to VF. If electricity becomes necessary due to lack of Magnesium availability and patient instability, most likely synchronized cardioversion will be impossible due to the constantly changing nature of the rhythm, and higher difibrillation doses will be needed, unsynchronized. The rhythm is more common in white women and in patients with severe nutritional deficiencies, such as chronic alcoholics, and thus IV Magnesium could be considered as "treating the underlying cause."

Is the patient stable?

The ACLS algorithms for bradycardia and tachycardia essentially start the same way. In a nutshell, place the patient on a monitor, establish IV, apply oxygen. You can obtain a 12 lead ekg if you have time (if the patient is stable, but don’t delay therapy.) The next box in the algorithm essentially defines stability. Does the patient have persistent chest pain likely casued by ischemia, is the patient hypotensive (typically a blood pressure less than 90 WITH SYMPTOMS, in other words, are there signs of shock, altered mental status, etc? Is the patient in acute heart failure? Stability is different than "symptomatic." A patient who is generally stable may be symptomatic- orthostatic hypotension, mild shortness of breath, mild discomfort , palpitations. These are all signs that the patient may be symptomatic, (or feel the arrhythmia), but they are not overt signs of instability. For the symptomatic patient, it may be prudent to monitor, observe, and obtain expert consultation. For the unstable patient, the prudent course of action is to act. Generally, the fastest course of action for the truly unstable patient is going to be electricity, either pacing, or cardioversion, depending on the algorithm. Drugs have their place as well, and can be effective. the point is not to delay definitive therapy in the unstable patient. Check out more posts at: http://www.carpentercprsolutions.com/-blog.html or check us out on facebook: https://www.facebook.com/Carpentercprsolutions

Supra Ventricular Tachycardia versus true Ventricular Tachycardia...

I am often asked how to differentiate between SVT with abberrancy (wide complex supra-ventricular tachycardia) from a true ventricular tachycardia, which is important to decipher the appropriate treatment, and the severity of the arrhythmia. a nice, easy way is the following: "In 2010 Joseph Brugada et al. published a new criterion to differentiate VT from SVT in wide complex tachycardias: the R wave peak time in Lead II [4]. They suggest measuring the duration of onset of the QRS to the first change in polarity (either nadir Q or peak R) in lead II. If the RWPT is ≥ 50ms the likelihood of a VT very high (positive likelihood ratio 34.8). This criterion was successful in their own population of 163 selected patients and is awaiting prospective testing in a larger trial. " In other words, if the beginning of the QRS and the peak of the complex (or trough of a downward deflecting wave) in lead II is more than 0.05 seconds, the chances are very high that you are dealing with ventricular tachycardia. If you will recall, each small box on a strip equals 0.04 of a second, or 40 milliseconds. Source: http://www.heartrhythmjournal.com/article/S1547-5271%2810%2900216-X/abstract

Heatstroke

In honor of summer, how about a quick discussion of heat related emergencies..... There are a few types of heat crises that need first aid. The cause is the same, too much exposure to hot weather for too long, probably doing too much work with too little to drink. Heat emergencies exist on a continuum, from not very severe, to immediately life threatening. First comes heat exhaustion, common from exposure to hot, humid environments in particular. signs include moist, pale, clammy skin, hefty sweating, usual body temperature, dizziness, annoyance and irritation, nausea and potentially vomiting, muscle cramps, and even fainting. The treatment is generally simple: move the person to a cooler environment, offer small, frequent amounts of cool fluids, remove excess clothing, and provide cool towels and rest. If the patient is not improving or continues to vomit, get further medical treatment. Heatstroke is at the far end of the spectrum. Heatstroke is a potentially life-threatening emergency with the hallmark sign of markedly increased body temperature, potentially above 106 degrees Fahrenheit. The victim may have, warm, dry skin; tachycardia, and unconsciousness. This patient requires 911 and immediate advanced intervention. First Aid would involve calling 911, have the person lie down if possible, get clothes off, and start lowering the body temperature immediately by any means necessary. (The AHA video shows a couple of guys holding the heatstroke victim in a pool submerged to the chest. Bonus points for creativity.) Hosing the person down and applying ice packs would certainly be appropriate.

Controlling bleeding: tourniquets and pressure

During first aid courses, we are often asked about tourniquets. Tourniquets are one way to stop severe uncontrolled bleeding, however, they are really a last resort. Generally, the first recommendation would be to diligently try to control the bleeding with direct pressure. Firm enough pressure will stop any bleeding, as long as it is firm enough and applied for long enough. Some bleeding is usually OK. It cleans out wounds. If the wound is severe, or the bleeding is prolonged, it becomes a problem. The first step in controlling a bleeding wound is to "plug the hole." Like moss on a rolling stone, blood will not coagulate when it's flowing. Regardless how severe, all bleeding can be controlled.. Most bleeding can be stopped before the ambulance arrives at the scene. While performing the steps for controlling bleeding, if it is severe enough, someone should also be calling for an ambulance to respond. The best way to stop it is to place pressure directly on the wound. Firm enough pressure will control any bleed. If gauze is available, it is preferred. Gauze pads hold the blood on the wound and help the components stick together and clot.. If you don't have gauze, any cloth will work almost as well. If the gauze or towel soaks through, add more on top Do not remove the gauze. Peeling a dressing off the wound removes vital clotting agents and encourages bleeding to resume.

Hands only CPR when help is far away..

Hands-Only CPR is a potentially lifesaving option to be employed by individuals not trained in basic life saving techniques. without immediate, effective CPR from a witness, a person's chance of survival is minimal. · AHA's 'hands-only' guidelines might not be best for rural areas though. According to new research, Hands-only CPR (CPR without mouth-to-mouth resuscitation), might not be the most effective technique for rural or remote areas or for anyone who needs to wait quite a few minutes for an ambulance. Literature reviewed by Dr. Aaron Orkin found very little evidence to support those guidelines outside of urban settings or in communities with no 911 services. His findings were revealed in the Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. Of the ten studies on saving lives with hands-only CPR he reviewed, only 1 included rural populations and people who had to wait longer than 15 minutes for an ambulance. a number of those studies showed that folks who waited longer for ambulances to arrive had a stronger likelihood of survival if mouth-to-mouth respiration was performed in addition to chest compressions. "Urban studies can't always be applied outside big cities," said Dr. Orkin, a doctor and graduate student attached with the University of Toronto, "Rural communities might need different CPR recommendations than urban settings," he said. http://www.carpentercprsolutions.com/1/post/2013/05/hands-only-cpr-when-help-is-far-away.html

Is more epi better?

Epinephrine is the primary drug administered per ACLS protocol to patients in asystole, PEA, and ventricular fibrillation/ pulseless V-tach. Epinephrine will increase blood pressure and coronary perfusion throughout CPR via alpha-1-adrenoceptor agonist effects. The dose, timing and indications for epinephrine use are supported based on animal data. Recent studies question whether or not epinephrine provides any overall benefit for human patients. A randomized controlled trial shows that epinephrine for out-of-hospital cardiac arrest will increase the rate of pulse return, however, it doesn't considerably alter longer-term survival. Large controlled studies suggest that, despite increases in pulse return, epinephrine reduces long-term survival (to hospital discharge.) The damaging effects were greatest in patients found in ventricular fibrillation. Laboratory information suggest that harmful epinephrine-induced reductions in microvascular blood flow throughout the arrest, and in the post-arrest patient, might offset the useful effects epinephrine-induced increase in blood pressure throughout CPR.