Intern Case Report Susan Seago 3/6/2015

66 yo F found down at home

ED Report EMS found her in sinus bradycardia with HR in 20s with episodes of ventricular bigeminy Transcutaneously paced en route to BSW with HR in 80s Taken off pacer in ED -> went into witnessed pulseless ventricular tachycardia -> one round of CPR -> back into sinus bradycardia with HR in 20s and ventricular bigeminy

Let’s back up…. PMH HTN HL Depression Hypothyroidism Takotsubo cardiomyopathy in 2011 repeat ECHO in 2013 wnl

PSH Social FH cholecystectomy neg cardiac cath 2011 1st grade teacher denies EtOH, smoking or IVDU FH denies FH of sudden cardiac death, premature CAD or CHF

Allergies Medications ACE (-) -> cough ASA 81mg Levothyroxine 100mcg Simvastatin 80mg qhs Metoprolol 50mg XL Fluoxetine 60mg qday Phenergan 12.5mg q6h prn Maxzide 25 Triamterene 37.5mg / HCTZ 25mg

Previous ECG

Prolonged QTc

Now back to the case... Physical exam Labs Temp 98.3 HR - 40s BP - 136/69 RR - 21 Gen - confused, not oriented Cardiac - bradycardia, irregular, no murmurs / gallops / rubs, no JVD or peripheral edema Labs WBC - 7.7, Hg - 12.2, Hct - 36.2, Plt - 158 Na - 145, K - 3, Cl - 110, C02 - 27, BUN - 9, Cr - 0.78, Glucose - 107 Ca - 8.2, Mg - 1.5 Troponin - 0.00

Long QT Syndrome Abnormal myocardial repolarization results in prolonged QT interval Both genetic and acquired Associated with life threatening ventricular tachyarrhythmias

Acquired Long QT Electrolyte abnormalities Hypocalcemia Hypomagnesemia Hypokalemia Hypothyroidism Drugs -> qtdrugs.org phenergan fluoxetine HIV Hypothermia Intracranial Disease Connective tissue disorders

Congential Long QT Syndrome Seven genetic mutations have been identified mutations with sodium and potassium channels in cardiac membrane lead to abnormal myocyte repolarization and prolonged QT

Ventricular Arrhythmias in Prolonged QT

Torsade de Pointes Polymorphic ventricular tachycardia progressive sinusoidal alteration of QRS axis appearing to twist around the isoelectric line

Back to our 66yo… Electrolytes were replaced, transcutaneously paced and transferred to CVICU Recovered quickly and hemodynamically stable throughout remainder of hospitalization Discharged with a life vest with outpatient EP follow up Recently had ICD placement and was back to teaching classes this fall

Questions??