Todays POTD inspired by a resuscitation case from Drs Kaplan and Odashima- a cardiac arrest pt whose reported initial rhythm was PEA got 4x Epi and bicarb and was then noted to have something similar to the following on EKG:

So lets talk Polymorphic Vtac and what we need to know
PVT- comes from multiple ventricular foci
  • Varying QRS complexes with different amplitudes, axis and duration
  • Normal QT?  think ischemia
    • Usually within 12hrs of onset of symptoms
    • Can be from severe CHF or cardiogenic shock
    • HIGH mortality with NO evidence of specific anti-arrythmic therapy improving mortality
    • TRX: 
      • Unstable> Defib
      • Stable> 5mg Metoprolol Q5min if BP tolerates
        • IV amiodarone may prevent recurrence
        • Urgent CATH, IABP
        • Mag is less effective
    • Can also be Familial catecholaminergic PVT
      • TRX:  Beta Blockers!
  • Torsades-must have PVT and QT prolongation
    • QRS "twist " around the isoelectric line
    • Often short lived and self terminating
    • MCC: Drugs
    • Electrolyte abnormalities- hypoK, hypoMg
      • Hypoglycemia? Can cause prolonged QT , but not commonly a/w ventricular dysrhythmias
        • The above patients BGM was around 30 could this be the cause of PVT?
        • Attached is an article regarding hypoglycemia induced arrythmias!  http://diabetes.diabetesjournals.org/content/63/5/1738
    • Initiates when PVC occurs during T wave= " R on T"
    • TRX: 
      • Unstable> Defib
      • Stable>MAG!!!
        • TV overdrive pacing at !100bpm
        • Congenital long QT- use BB to shorten QT
        • 2* bradycardia- Isoproterenol 2mcg/min
A few more Pearls courtesy of LITFL!
Sources: Uptodate, LITFL