Recurrent Polymorphic VT/Torsades de Pointes - Management Algorithm
Drugs that prolong QT interval:
• Class 1a (quinidine, disopyramide)
• Class 1c (flecainide)
• Class 3 (amiodarone, dofetilide, sotalol)
• Propofol
• Chloraquine (antimalarial)
• Macrolides and quinolones
• Antipsychotics (haloperidol, chlorpromazine)
• Antidepressants (citalopram, escitalopram, amitriptyline)
• Fluconazole, ketoconazole
• Cocaine
• Methadone
• Ondansetron
• Domperidone
• Donepezil
Congenital long QT Syndrome
Electrolyte Abnormalities:
Hypomagnesemia
• Hypokalemia
• Hypocalcemia (rarely)
Treatment Of Recurrent TdP
First line: magnesium sulfate
• Adult load: 2-4 gm over 10-15 minutes
• Adult infusion after load: 0.5-1 gm/hour
• Pediatric load: 25-50 mg/kg over 10-15 minutes
Increasing chronotropy (goal 90-110 bpm)
• Prevents future TdP. Does NOT treat current TdP
• Isoproterenol (non selective beta agonist)
• Adult: 0.5-5 mcg/min
• Pediatric: 0.1-1 mcg/min
• Overdrive pacing (transcutaneous or transvenous)
Anti-arrhythmic
• Class 1b (lidocaine)- case report level evidence
• Load: 1-1.5 mg/kg
• Infusion: I mg/min
Stacy Marshall, MD
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