Cardiac Arrest in a Patient With Torsades de Pointes

Vital Signs

Noted before cardiopulmonary arrest:

• Temperature: 98.6 °F, axillary

• Blood Pressure: 80/40 mmHg

• Pulse: 180 beats per min (bpm)

• Respiratory Rate: 18 breaths per min

• Pulse Oximetry: 85% oxygen saturation on 4 L nasal cannula

Focused Physical Examination

The pre-arrest examination showed a middle-aged female in mild distress. The patient appeared drowsy with slowed responses. Appropriate personal protective equipment was established, and the patient was examined. Her cardiac exam showed tachycardia with normal heart sounds, and no new murmurs were appreciated. Her lung exam showed decreased breath sounds bilaterally with prominent crackles at lung bases. The patient became unresponsive and lost her pulse during the exam, and cardiopulmonary resuscitation (CPR) was started.

Interventions

A cardiac monitor and defibrillator pads had already been attached when the RRT arrived at the patient’s room. Telemetry findings were consistent with Torsades de Pointes (TdP) with cyclical alterations of the QRS complex around the isoelectric line ( Fig. 16.1 ). Based on recent labs, 2 g of intravenous magnesium had already been ordered by patient’s primary team and was in the process of being administered. After the patient’s rhythm degenerated to pulseless ventricular fibrillation, CPR was initiated immediately. The airway was secured via endotracheal intubation. The patient was defibrillated at 200 J, and one ampule of 1 mg epinephrine was administered. Return of spontaneous circulation was achieved in under 2 min. Post-arrest telemetry strip showed sinus tachycardia. A 20 meq IV bolus of potassium was given, followed by an infusion rate of 20 meq/h via a central line. The patient was started on an infusion of norepinephrine for hemodynamic support and transferred to the intensive care unit for further care.