1. Intern Case Report
Susan Seago
3/6/2015

2. 66 yo F found down at home

3. 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

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

6. 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

7. 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

8. Previous ECG

9. Prolonged QTc

10. Now back to the case... Physical exam Labs
Temp 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 , Hct , Plt - 158
Na - 145, K - 3, Cl - 110, C , BUN - 9, Cr , Glucose - 107
Ca - 8.2, Mg - 1.5
Troponin

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

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

17. 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

18. Ventricular Arrhythmias in Prolonged QT

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

20. 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

21. Questions??