Torsades duration of tachycardia, degree of cerebral hypoperfusionRapid

Torsades De Pointes – Lethal form of Ventricular TachycardiaPatient-centered Holistic Assessment Focused Assessment (Beattie, 2004)Episodes of palpitations, dizziness, syncopeNausea, cold sweats, shortness of breath, chest pain – nonspecificWith Congenital long QT syndrome – episodes are triggered by adrenergic stimulationStress, fear, physical exertionAsking the patient about current medications (drug-induced torsade)Rate and duration of tachycardia, degree of cerebral hypoperfusionRapid pulse, low/normal BP, transient/prolonged loss of consciousnessPreceded by bradycardia or PVC’sPallor, diaphoresisComorbidities (Beattie, 2004)Cardiac deathCongenital long QT syndromeDevelop torsade during periods of bradycardiaCaused by: medications and electrolyte disorders (hypokalemia, hypomagnesemia)Acquired LQTSCongenital deafnessRomano-Ward syndromeDrug-associated torsadesRisk Factors (Beattie, 2004)Takotsubo cardiomyopathy, acquired conditions decreasing outward potassium current or interfering with inward sodium and calcium currents, fluxesElectrolyte disturbances – hypokalemia, hypomagnesemia, hypocalcemiaAntiarrhythmic drugs – class 1A (quinidine, procainamide, disopyramide), Class 1C (encainide, flecainide), class 3 (sotalol, amiodarone)Antihistamines astemizole and terfenadine – DO NOT USE WITH CLASS 1A, 1C or 3 agents – precipitate torsade when used with azole antifungals or macrolide antibioticsPhenothiazines, tricyclic antidepressants, lithium carbonate, ziprasidone, cisapride, highly active antiretroviral drugs, high-dose methadone, anthracycline chemo (doxorubicin, duanomycin), fluoroquinolones, any medication with the CYP3A pathway, ranolazine (anti-angina)Congenital Long QT syndrome, Female gender, acquired long QT syndrome (meds, electrolytes disorders), bradycardia, baseline ECG abnormalities, renal and liver failureFamily history of unexplained cardiac death, TorsadesPatients with ischemic/hypoxic damage to brain, ANS dysfunction, adrenal insufficiency/Addison’s disease, severe imbalances in vitamins or minerals, neurological disorders, brain traumaHistory of slow HR, prolonged QT syndrome, low blood pressure under age 40LQTS – RisksGenetic defect, medications, hemorrhagic stroke, mitral valve prolapse, fasting and liquid protein diets, females, agePsycho-social-emotional Health (Mitchell, 2017)Sudden unexpected anxiety, panic, claustrophobiaFainting and blacking out, repeated episodes of chest painHypochondriac complaints, psychosomatic chest painEnsure to allow the patient to express these feelings and make the patient feel heard. There is a chance the patient has been labeled as a hypochondriac due to feelings and symptoms related to this disease process.Clinical Manifestations Certain Symptoms of Torsade de Pointes require immediate interventions (Beattie, 2004)Reactions to drugs up to 48 hours after administrationRationale: For drug induced TdP, the drug needs to be stopped immediately, but the patient must be monitored until the drug has been metabolized out of their system. EKG – normal before and 5 minutes afterArrhythmias, increased PVC’sRationale: An EKG will show the polymorphic QRS complex, but will be normal before and 5 minutes after TdP episode, so a continuous EKG monitoring is necessary.Significant increase in HR, Unexplained onset of chest pain, Fluttering sensations, irregular or pounding HRRationale: These symptoms can be prerequisites to a TdP episode, warning the patient. Immediate attention may be necessary to treat the episode and prevent cardiac arrest. Unexplained syncope when going from laying to sitting or sitting to standingRationale: Syncope can be a dangerous symptom of TdP. Patients need to be forewarned of this symptom, and preceding symptoms that may warn the patient of fainting. If a patient has had a fainting spell(s), it targets which treatment may be most beneficial.HALLMARK FEATUREPolymorphic QRS Complex twisting around the isoelectric lineSources of Clinical InformationThis may include patient complaints, symptoms the patient has been experiencing and relation to the disease process, basic telemetry monitoring, HR values, BP values, medication reconciliation.The main source of information is going to be the patient and the EKG.Nursing ImplicationsDiagnostic studiesEKG (Mitchell, 2017)Change in QT interval – long QT waveProlonged time for the ventricles to contract and recover – extended repolarizationMyocardial cells less refractory to electrical stimuli, more likely to depolarize prematurelyWatch for a progressing lengthening in the QT interval (at risk patients)Normal QT interval is 400 ms or 0.40 seconds)QT interval – beginning of Q-wave to end of T-waveQTc – number of seconds of RR interval, square root RR interval, divide the QT interval by the RR interval square root – repeat for 5 beats – add together and divide by 5 (the average is most important in determining an ongoing problem)Abnormal QTc – >450ms for men and >460 ms for womenImage 1 shows the EKG of a patient with TdP. (Mitchell, 2017)Medications to treat TdP (Mitchell, 2017)Magnesium Sulfate IV2 gram over 1-2 minutes if unresponsive, 2nd bolus given after 5-10 minutes and a infusion of 3-20 mg/minDo not give infusion to patients with renal insufficiencyWhile administering, BP should be monitored as well as DTR’s and serum electrolytes (Karch, 2017)Beta BlockersIV isoproterenol It acts to increase the HR, has a positive inotropic effect, bronchodilation and vasodilation (Karch, 2017)It can cause restlessness, apprehension, anxiety, fear, cardiac arrhythmias, tachycardia, nausea, vomiting, heartburn, respiratory difficulties, coughing, pulmonary edema, sweating and pallor (Karch, 2017)LidocaineShortens the QT interval – effective for drug induced TdPLidocaine reduces sodium permeability, reducing the height and rate of the action potential, increases the excitation threshold and slows the conduction velocity (Karch, 2017)It can cause headaches, backaches, hypotension, urinary retention, urinary incontinence, pruritus, and seizures (Karch, 2017)Avoid Class 1A, 1C, and III antiarrhythmicsCAM for TdPAvoid strenuous exercise if exercise precipitates attacks (Mitchell, 2017)Nursing InterventionsEnsure that there are not any loose or disconnected leads causing the pattern (Dave, 2017) Resuscitation, if needed (Dave, 2017)Assess electrolyte levels and correct any unstable ones (Dave, 2017)Never use Methadone!! (deadly)Do not use Zomig or Hydralazine (deadly)Sublingual nitro spray – stops attacksImdur ER (30-60 mg) prevents attacksAcquired LQTS – Stop offending drug causing Torsade attacksThe drug induced TdP may still need to be treated even after the drug is stopped due to half-life of the offending drug. Until the drug is completely cleared from the body, TdP may still occur. This can be treated with temporary pacing, IV isoproterenol, or both. (Mitchell, 2017)Congenital LQTSBeta-adrenergic antagonists (propranolol, esmolol)Blunt the surge of adrenaline that triggers TdPPermanent pacemaker or implantable cardioverter defibrillator (ICD) (Beattie, 2004)Combination of the above methods (Mitchell, 2017)Patients should avoid drugs that prolong the QT Interval and avoid strenuous exercise (if exercise precipitates symptoms) (Mitchell, 2017)TdP management NEVER give usual antiarrhythmic agents used to treat ventricular tachycardiaThese drugs may prolong the QT interval and cause deathPrepare to defibrillate a symptomatic patientPrepare mag sulfate IV push or infusion (even if serum mag level is normal)Antiarrhythmic medicationsLidocaine, phenytoin, isoproterenolOverdrive pacing – amiodaronePatient’s family members should be evaluated by EKG as well, because this disease can be genetic. (Mitchell, 2017)Interventions for EKG (Antipeusto, 2014)Prepare the patient for the EKG by educating them on the procedureThe patient must lie still, relaxed with normal breathingQuestion the patient on any current drug therapy, pacemaker, or chest painThe EKG takes 5-10 minutes and is painlessImplement EKG measuringPlace patient supine or in semi-fowler position, exposing chest, ankles, and wristsPlace electrodes on inner wrists, medial ankles, and on chestConnect the lead wires and press startEnsure all leads are represented in the tracingDisconnect equipment, remove electrodes, and removed gel with moist towelNormal EKG MeasuresP wave is <2.5mm in height and <0.12 seconds in lengthPR interval is 0.12-0.2 seconds for HR > 60 beats/minQT interval varies with HR and lasts 0.4-0.52 seconds for HR > 60 beats/minuteVoltage of R wave is < 27mmTotal QRS lasts 0.06-0.1 secondComplications - Prioritize interventions using Maslow'sComplications of TdP include Ventricular Tachycardia, Ventricular Fibrillation, sudden cardiac death, and death Priority intervention is unsynchronized cardioversion with 100 joules or Magnesium Sulfate IV bolus and rest to prevent worsening of the TdP and to help relieve symptoms (physiological needs) (Mitchell, 2017)Congenital syndromes of TdP that are may repeat may necessitate long term treatment with permanent pacing, ICD or a combination of medications and permanent Pacing...this will ensure that their rhythm and rate are continuously monitored (safety needs) (Mitchell 2017)This patient needs to be informed that this disease can be genetic, and psychosocially this may worry the patient of their kids and family members. A priority intervention in this case is to get an EKG for all family members who may be at risk for TdP (belongingness and love needs) Patient must be involved in all decisions so that they can feel as though they are a part of their own care (esteem needs) Ensure that the patient is aware of what activities they can still safely participate in and help them find other things that they may like doing if there is anything the doctor recommends they stop (self-actualization needs) Patient participation in decision-makingWhen it comes to long term, repeating TdP, patients may have a say in the long term treatment they might receive. They can decide between trying medications, what kind of permanent pacer they want, or a combination of them for treatment methods.Patients who have been resuscitated or have experiences syncope despite use of beta blockers should be advised to use an ICD for treatment. (Mitchell, 2017)Patients who are involved in their own care plan may be more likely to participate and follow through with the care that is needed for them. While TdP doesn't have many avenues of treatment, the patient should be involved in deciding which avenue to take first. If the patient knows they are not good at medication adherence, then it is possible that an ICD would be the better avenue of treatment for them.Interprofessional team involvementCardiologist Psychiatrist (possibly due to tricyclic antidepressant or Phenothiazine involvement) Pharmacist (Tisdale, 2016)Pharmacists must be made aware of patients that are at risk for TdP (certain risk factors place individuals at a much higher risk)There are many medications that can cause TdP and pharmacists are one of the first lines in ensuring that at-risk patients do not receive medications that contradict with their diagnosis (Tisdale, 2016)Priority for patient education and discharge plan Priority patient education It would be extremely important to educate the patient about which types of medications increase their risk for this so that they feel empowered to ask for alternatives if need beFurthermore, just like any other disease process, the patient needs to be educated on the early signs and symptoms so that they can get to the hospital as quickly as possible, since disregarding the symptoms of this can be deadly Discharge care plan Patient will stay off all precipitating medications and take all new prescribed medications even if/when they are not having symptoms Patient will attend all follow-up cardiology appointments, lab appointments, and diagnostic studies that are scheduledPatient will demonstrate that they have an understanding of what signs and symptoms should bring them into the ERPatient will work on lowering the stress level in their everyday life and limiting strenuous exercise Patient will have a plan in place for any emergency situation (e.g., make people close to you aware of your diagnosis) In times of sickness, make sure to push fluids and keep temperature down to decrease the chance of any electrolyte imbalance Priority nursing intervention with measures and evaluationsContinuously assess electrolyte levels and correct any disturbances (Dave, 2017)Can measure electrolyte levels with frequent blood draws Normal sodium is 135-145 mEq/LNormal chloride is 96-106 mEq/LNormal calcium is 8.9-10.1 mEq/LNormal potassium is 3.5-5.0 mEq/LNormal magnesium is 1.5-2.0 mEq/LHypokalemia and hypomagnesia are two of the most common electrolyte disturbances that can result in TdP