Life-threatening Dysrhythmias Research Articles

#3073 Should we expand the indications for hemodialysis in lithium intoxications beyond the EXTRIP recommendations?

Abstract Background and Aims EXTRIP Workgroup (EW) recommends renal replacement therapy (RRT) in lithium poisoning when serum lithium levels >4 mmol/l in cases of impaired kidney function, decreased consciousness, seizures or dysrhythmias, and suggests RRT in cases of serum lithium >5 mmol/l or when there is confusion or the expected time to obtain lithium levels <1 mmol/l with optimal management exceeds 36 hours. The aim of this study was to assess the benefit of RRT in the conditions recommended and suggested by the EW, and evaluate the benefit from RRT in other conditions of lithium poisoning. Method We conducted a retrospective mutli-centre observational study that included patients with a diagnosis of lithium poisoning from January 2006 to December 2022. Demographic data, kidney function and comorbidities, clinical presentation including neurologic, cardiac and renal manifestations, type of intoxication, previous poisonings or concomitant intake of other toxic substances and treatments used were registered. In patients receiving RRT, the type of RRT, duration and number of sessions were registered. Lithium levels during hospitalization were recorded, and time for lithium levels <1 mmol/l was calculated. The primary outcomes were death from lithium poisoning and persistent neurologic deficits (syndrome of irreversible lithium-effectuated neurotoxicity, SILENT). Results The study included 179 cases of lithium poisoning (62.6% chronic lithium poisoning, 34.6% acute on chronic and 2.8% acute poisoning),with a mean age of 56.3 ± 15.4 years, and patients were predominantly females (57%). 130 patients (72.6%) presented neurological manifestations, out of which 33 patients (18.4%) presented a decreased conscious level or generalized convulsions, and 40 patients (22.3%) presented confusion. 98 patients (54.7%) presented acute kidney injury (AKI) and 21 patients (11.7%) presented life-threatening dysrhythmias. 68 patients (38%) were treated with RRT. 31 patients (17.3%) developed persistent neurological deficits (SILENT) and only 2 patients (1.1%) died of lithium poisoning during hospitalization. Concerning patients in whom hemodialysis was recommended according to EW guidelines, only 34 out of 53 patients (64.2%) received RRT. In this group of patients, those who received RRT developed less frequently SILENT (11.8% vs 36.8%, p = 0.031) Regarding patients in whom hemodialysis is suggested according to EW, only 34 out of 106 patients (32.1%) received RRT. Overall, combining patients in whom dialysis is recommended or suggested according to EW, SILENT developed less frequently in those who received RRT (13.2% vs 20.4%) Beyond the recommendations by the EW, we found that patients with lithium levels > 2 mEq/l with AKI and any neurological manifestations presented less frequently SILENT when receiving RRT (7% vs 26%, p = 0.033). We also observed that patients who received RRT had a shorter in-hospital stay (3.3 [IQR 2-7] days vs 9.4 [IQR 5-11] days, p = 0.01). Conclusion Patients presenting with lithium poisoning and impaired kidney function or any neurological manifestations who received RRT presented less frequently persistent neurologic deficits (SILENT) after discharge, regardless of lithium levels or type of poisoning. We suggest that EXTRIP should recommend RRT in any patient with lithium poisoning who presents with neurological symptoms or impaired kidney function, regardless of lithium levels.

A Narrative Review of Aconite Poisoning and Management.

Aconite poisoning refers to toxicity resulting from plants belonging to the Aconitum genus, which comprises over 350 different species of perennial flowering plants that grow in temperate mountainous areas of the northern hemisphere (North America, Europe, Asia). These plants contain a group of toxins known as aconite alkaloids, which encompass numerous closely related toxic compounds. Conventional teaching from toxicology textbooks has broadly classified these alkaloids based on their mechanism of action, often simplifying them as substances that prevent sodium channel inactivation. However, this is an oversimplified and sometimes inaccurate description, as some aconite alkaloids can act as sodium channel blockers. Aconite alkaloids have a long history of use as poisonous substances and have been historically employed for hunting, assassinations, traditional medicine, and self-inflicted harm. Toxicity can occur due to the consumption of traditional medicines derived from aconitum plants or the ingestion of aconite plants and their derivatives. The clinical manifestations of aconite poisoning may encompass gastrointestinal symptoms, sensory alterations, seizures, and life-threatening dysrhythmias that may not respond to standard treatments. Treatment is primarily supportive however evaluation and management of these patients should be personalized and carried out in collaboration with a toxicologist.

Effects of Anesthetics on Cardiac Repolarization in Adults: A Network Meta-Analysis of Randomized Clinical Trials.

Prolongation of cardiac repolarization, especially the heart rate-corrected QT (QTc) interval, is associated with life-threatening dysrhythmias. This study aimed to identify the anesthetic with the lowest risk of prolonging cardiac repolarization and provide guidance for anesthesia management in patients with cardiac diseases or long QT syndrome. Randomized controlled trials (RCTs) comparing the effects of anesthetics on cardiac repolarization indices were searched for in multiple databases. The primary outcome was QTc; and the secondary outcomes were other repolarization indices. A network meta-analysis was conducted using a frequentist approach and registered with the International Prospective Register of Systematic Reviews (PROSPERO) database (CRD42022304970). Thirteen RCTs investigating 953 adults with normal QTc interval and without cardiovascular diseases were included. Direct meta-analyses found that propofol had less influence than sevoflurane (95% confidence interval (CI): 16.10, 33.54) and desflurane (95% CI: 4.85, 35.36), and sevoflurane had less influence than desflurane (95% CI: 6.96, 19.39) on QTc prolongation. Network analysis found that propofol had less influence than sevoflurane (95% CI: 17.78, 29.63), halothane (95% CI: 11.29, 41.24), desflurane (95% CI: 23.79, 39.88), and isoflurane (95% CI: 20.11, 46.10), and sevoflurane had less influence than desflurane (95% CI: 0.43, 15.82) on QTc prolongation. The rank order of cumulative ranking curve analysis was propofol (100%), sevoflurane (63.8%), halothane (49.5%), desflurane (21.1%), and isoflurane (15.6%). The direct meta-analysis found that propofol had less influence than sevoflurane on QT prolongation (95% CI: 23.12, 57.86). Other secondary outcomes showed no conclusive findings. This meta-analysis found that propofol had a minimal effect on QTc prolongation, followed by sevoflurane and desflurane in adults with normal QTc interval and without cardiovascular diseases. Propofol is the best anesthetic for adult patients with long QT syndrome or cardiac diseases, but still needs more robust evidence.

Cardiac events after using clarithromycin for anti-Helicobacter pylori therapy in patients with coronary artery disease.

Clarithromycin is an antibiotic commonly used to treat Helicobacter pylori infections. The US Food and Drug Administration (FDA) advises caution before prescribing clarithromycin to patients with cardiac diseases. This study aimed to evaluate cardiac events after anti-H pylori treatment in patients with coronary artery disease. A retrospective 5-year study was conducted on outpatients who received anti-H pylori therapy. Among the 7855 patients receiving therapy, 228 patients (2.9%) underwent angiography with coronary artery disease before therapy, and 193 patients received clarithromycin. Clarithromycin users seemed not to be at risk for cardiac events as compared with non-clarithromycin users at 3 months (4.7% vs 2.9%, P = .63) and 1 year (10.9% vs 5.7%, P = .35). Neither life-threatening dysrhythmia nor cardiac death was noted. The risk factors for cardiac events within 3 months after therapy were smoker (OR:5.38, 95% CI:1.39-20.78), and events within 1 year were smoker (OR:3.8, 95% CI:1.41-10.22), and diabetes mellitus (OR:5.68, 95% CI:1.9-16.98). Among patients with coronary artery disease who received anti-H pylori therapy, short-term cardiac events did not increase in clarithromycin users but should be considered in diabetic and smoking patients.

The Uncertain Benefit from Implantable Cardioverter-Defibrillators in Nonischemic Cardiomyopathy: How to Guide Clinical Decision-Making?

Life-threatening dysrhythmias remain a significant cause of mortality in patients with nonischemic cardiomyopathy (NICM). Implantable cardioverter-defibrillators (ICD) effectively reduce mortality in patients who have survived a life-threatening arrhythmic event. The evidence for survival benefit of primary prevention ICD for patients with high-risk NICM on guideline-directed medical therapy is not as robust, with efficacy questioned by recent studies. In this review, we summarize the data on the risk of life-threatening arrhythmias in NICM, the recommendations, and the evidence supporting the efficacy of primary prevention ICD, and highlight tools that may improve the identification of patients who could benefit from primary prevention ICD implantation.

QTc Prolongation in Poison Center Exposures to CredibleMeds List of Substances with "Known Risk of Torsades de Pointes".

Many drugs carry some risk of QT interval prolongation, which can lead to life-threatening dysrhythmias including Torsades de Pointes (TdP). CredibleMeds.org identifies medications categorized as "Known Risk of TdP" but does not stratify risk in acute supratherapeutic ingestions. We sought to determine the proportion of cases exhibiting QTc prolongation and life-threatening dysrhythmias including ventricular tachycardia (VT)/ventricular fibrillation (VF), TdP, and asystole in patients exposed to these substances. Retrospective chart review of cases reported to our Regional Poison Center from 2014 to 2019 of exposures to one or more of the "Known Risk" substances was performed. Demographics, therapies, clinical effects, and medical outcome for each case were analyzed. There were 1125 exposures, of which 760 had a documented QTc interval. QTc ≥ 500ms was reported in 138 (18.2%) of the 760 cases. The most common "Known Risk" substances were citalopram, escitalopram and cocaine. Although not in the "Known Risk" category, mirtazapine, amitriptyline, diphenhydramine, and trazodone had a statistically significant association with QTc > 500ms. Life-threatening dysrhythmias occurred in 13 cases, with VT/VF in 6 of the 760 (0.8%) cases, and one case of TdP. Flecainide (OR 11.1, 95% CI 2.2-55.8) and methadone (OR 7.1, 95% CI 2.1-23.4) were associated with increased risk of all life-threatening dysrhythmias. Exposures to medications on the Credible Meds list of "Known Risk of TdP" QTc prolongation is common, but life-threatening dysrhythmias are rare. Mirtazapine, amitriptyline, diphenhydramine, and trazodone were associated with prolonged QTc. Flecainide and methadone had the highest associated risk of life-threatening dysrhythmias.

Debunking the myths of acute hyperkalemia treatment

The article provides an overview of the world data on modern approaches to the treatment of patients with hyperkalemia according to the principles of evidence-based medicine. Hyperkalemia is a common and potentially fatal condition that affects millions of people throughout their lives. Despite the prevalence and severity of this condition, there are no consensus recommendations for the treatment of hyperkalemia. The authors noted that a standard approach would likely improve outcomes. Further complicating the situation is that there is not even a universal definition of hyperkalemia. Historically, approaches to the treatment of acute hyperkalemia have been based on three concepts: «stabilization» of the cardiac depolarization threshold, intracellular displacement of serum potassium, and elimination of total potassium in the body. The urgency of these actions is often determined by ECG findings, as life-threatening dysrhythmias can occur over a wide range of serum potassium concentrations. Because of the difficult nature of prospectively assessing a life-threatening condition, many of these ideas have been entrenched for generations despite a lack of evidence to support them. Objective. To review information sources devoted to modern approaches to the management of patients with acute hyperkalemia, modern diagnostics, modern treatment protocols in order to establish optimal methods of treatment of patients, prevention of complications and early recovery and development of recommendations in Ukrainian. The article provides a brief overview of the most significant errors encountered in emergency care in hyperkalemia, reviews the currently available literature and discusses the practical aspects of several methods of hyperkalemia treatment. Misconceptions and disagreements about its treatment have led to controversial treatment strategies. The article reviews four of the most common myths and provides recommendations based on the interpretation of the available data. At the end of each section, recommendations from open sources are provided to help emergency physicians, internists, nephrologists, and anesthesiologists make safe and effective choices in the treatment of acute hyperkalemia. Conclusion. Hyperkalemia is a common and potentially life-threatening electrolyte disorder. Misconceptions and disagreements about its treatment have led to controversial treatment strategies. This article reviews four of the most common myths and provides recommendations based on the interpretation of the available evidence. We recommend that clinicians continue to evaluate the available evidence and make treatment decisions based on the balance between the potential benefits and harms of each of these interventions.

Simulation Improves Internal Medicine Resident Confidence With Defibrillation, Cardioversion, and Transcutaneous Pacemaker Use.

IntroductionWhile many graduate medical education programs require residents to be certified in advanced cardiac life support, this does not cover all aspects of cardiac stabilization in patients with a pulse. Residents are often on the front lines of providing care to patients with life-threatening dysrhythmias. Our residents expressed a lack of confidence in their ability to provide this care.MethodsA convenience sample of internal medicine, preliminary medicine, and transitional year residents from our large community-based tertiary care hospital participated in our survey and training. We utilized a pre-post survey method of our residents’ confidence in domains that are critical to caring for patients requiring cardiac resuscitation and stabilization. Our pre-post survey was a modified Likert scale. Our training consisted of a 1-hour faculty-led hands-on training session focused on these critical domains in our hospital’s simulation suites. Follow-up survey data were collected immediately after the training and at six and 11 months after the training using mean confidence across all five domains as the study variable.ResultsResident mean confidence in the five domains (placing leads and pads, manipulating defibrillator controls, performing defibrillation, performing synchronized cardioversion, and performing transcutaneous pacemaker use) increased immediately after our training compared to before the training (p<0.001). This increase in confidence from before the training was sustained at six and 11 months after the training (p=0.001 and p=0.002, respectively). Confidence was lower at six and 11 months than immediately after training (p=0.01 and p=0.004, respectively).ConclusionOur project showed that simulation-based training was effective in improving our trainee’s confidence in providing care to patients with life-threatening dysrhythmias. As with previous studies in simulation, confidence degradation was seen over time and likely mirrors skill degradation in these low-frequency encounters. As such, future aims include identification of ideal time intervals between training.

Synthetic cathinone poisoning from ingestion of drug-laced "instant coffee packets" in Taiwan.

Synthetic cathinone abuse is a global health issue. Synthetic cathinones emerged in Taiwan in 2009, and their prevalence rapidly rose. They are usually made into "instant coffee packets," and these so-called "toxic coffee packets" may also contain psychoactive drugs other than synthetic cathinones. Due to the diversity of the ingredients, clinical presentations can be complex. Retrospective analysis of emergency department (ED) patients who reported ingesting toxic coffee packets at three Chang-Gung Memorial Hospitals located in northern Taiwan between January, 2015 and December, 2019. Sixty patients were included. Their mean age was 28.85 ± 9.24 years and 47(78.33%) were male. The most common presentations were palpitation, agitation, hallucination, and altered consciousness. Tachycardia and hypertension were common, while hyperthermia was observed in only three patients. Three patients (5%) developed rhabdomyolysis, and one underwent transient hemodialysis. Most patients were discharged from the ED, but 15(25%) were admitted, of whom nine (15%) were admitted to the intensive care unit (ICU), and one eventually died. Confirmation tests (mass-spectrometry-based analysis) were available in 10 patients; all reported positive for at least one type of synthetic cathinone. Polysubstance exposure was common. In multivariate logistic regression analyses, Glasgow coma scale ≤13 and the presence of seizure were associated with ICU admission. Patients who report ingesting toxic coffee packets are very likely to have been exposed to synthetic cathinones. Polysubstance exposure is common following ingestion. Cardiovascular and neurological symptoms are the main presentations, and severe complications such as rhabdomyolysis and life-threatening dysrhythmia can occur.

Unmasking Long QT Syndrome in the Emergency Department: A Case Report.

IntroductionLong QT syndrome (LQTS) is an uncommon disorder that can lead to potentially life-threatening dysrhythmias. LQTS can be genetic, acquired, or both.Case ReportA 44-year-old female with well-controlled hypertension and asthma presented with chest tightness. An initial electrocardiogram yielded a normal corrected QT interval of 423 milliseconds (ms) (normal <480 ms in females). Albuterol was administered and induced agitation, tremulousness, and tachycardia. Follow-up electrocardiograms demonstrated extreme prolongation of the corrected QT interval to 633 ms and morphology change of the T wave. Lab values were later notable for hypokalemia and hypomagnesemia, attributable to a recently started thiazide diuretic. The patient was ultimately diagnosed with congenital LQTS after initial unmasking by albuterol in the emergency department.ConclusionLQTS can be unmasked or exacerbated by electrolyte abnormalities and QT prolonging medications.

Critical Care Nurses' Competency Regarding Early Prediction and Interpretation of Life-Threatening Dysrhythmias: Life – Saving Opportunity

Background: Life-threatening dysrhythmia, especially the ventricular, is one of these conditions that if not predicted and treated promptly can cost a patient's life. Also, it remains one of the most common causes of sudden death in critically ill patients. Early prediction of life-threatening – dysrhythmias can be considered as a life–saving opportunity for critically ill patients (Maurice et al., 2017; Dinnah, 2018). Aims: aims of the current study were to assess the critical care nurses' competency (knowledge) towards early prediction and interpretation of life-threatening dysrhythmias and to identify the obstacles that prevent nurses from acquiring competency regarding the early prediction and interpretation of life-threatening dysrhythmias. Methods: A descriptive cross-sectional study design was recruited to conduct the study. Data was collected from a convenient sample of 100 nurses working in critical care settings at Main University Hospital. A self-reported three-part- questionnaire using a paper pencil was used to collect the data of this study. Results: the result of the current study showed that critical care nurses had a very low level of competency required for early prediction and interpretation of life-threatening dysrhythmias (75% of the participants failed to identify or determine the types of dysrhythmia). Moreover, nearly three fourth of nurses did not attend any educational training about dysrhythmias. Significant correlations were found between nurses’ competency, level of education, and nurses’ position in the critical care units [(most nurses who failed to answer all questions were diploma graduate (85.5) and (excellent knowledge score was significantly higher in staff nurses than other positions although their frequency was relatively low (MCp.001)]. However, there was no significant correlation existed between the level of nurses' competency and other variables such as age, sex marital status. Finally, four obstacles were identified preventing the acquiring of required competency. Conclusions: The present study concluded that critical care nurses have a drastic low level of knowledge concerning the competency of early prediction and interpretation of life-threatening dysrhythmias. Moreover, significant correlations were found between nurses' competency, level of education, and their position in critical care units. However, there was no significant correlation between the nurses' competency and other variables such as age, sex, and marital status more than three-quarters of the nurses did not attend any training related to dysrhythmia. Finally, four factors were identified by the nurses as obstacles for acquiring competency of early prediction and interpretation of life-threatening dysrhythmias.

Clinically relevant adverse cardiovascular events in intermediate heart score patients admitted to the hospital following a negative emergency department evaluation.

Study objective: To estimate the frequency of clinically relevant adverse cardiac events (CRACE) in patients admitted to the hospital for chest pain with an intermediate HEART score (4, 5, 6), non-diagnostic EKG, and a negative initial troponin. We conducted a retrospective analysis of all patients admitted to the University of Maryland Medical Center (UMMC) from May 2016 to May 2019 with an intermediate HEART score (4, 5, or 6), a non-diagnostic EKG, and a negative initial troponin. Our primary outcome was the rate of inpatient clinically relevant adverse cardiac events (CRACE), composite of life-threatening dysrhythmia, inpatient STEMI, cardiac or respiratory arrest, and all-cause mortality during hospitalization. A total of 1118 patients met our inclusion criteria, 6 of whom had CRACE. Overall the rate of CRACE was 0.5% (95% CI, 0.2-1.2%). Six patients (0.5%, 95% CI, 0.2%-1.2%) experienced inpatient NSTEMIs, 212 patients (19%, 95% CI, 17-21%) underwent provocative testing during their inpatient stay, 5 patients received a stent or CABG, and 5 patients had false positive non-invasive testing and underwent a negative cardiac catheterization. In this cohort of admitted patients with a documented intermediate-risk HEART score, nonischemic EKG, and negative initial troponin, the occurrence of CRACE during the index hospitalization was 0.5%.

Evaluation of QRS, QTc, and JTc intervals in Congenital Heart Disease with Pulmonary Hypertension

Background Pulmonary hypertension (PH) in congenital heart disease affects the patient’s prognosis. Prolonged QRS and QTc intervals in ECG may intensify life-threatening dysrhythmia in patients. We aimed to investigate the correlation between QRS, QTc, and JTc intervals prolongation in ECG with PH in Congenital Heart Disease (CHD) patients. Materials and Methods: This cross-sectional study was performed in the pediatric cardiology clinic of Be’sat Hospital in Hamadan, Iran, in 2016-2018. Patients with CHD and PH were compared with CHD patients without any evidence of PH as the control group. Afterward, QRS, QTc, and JTc intervals in ECG, RV MPI, and TAPSE echocardiography were compared between the case group (PH group) and the control group. We also compared the ECG and echocardiographic results between mild and severe PH patients in the case group. Results: In this study, 40 patients in the case group (with CHD and PH) were compared to 40 patients in the control group (only CHD without PH). There was a significant difference in QRS (p=0.005) and QTc (p=0.036) intervals between the two groups, but no significant difference in the JTc interval was observed. Of 40 patients with PH, 19 were in the mild PH subgroup, and 21 were in severe PH subgroup, in which 9 patients had irreversible PH or Eisenmenger syndrome (ES). QTc (p<0.001) and QRS (p=0.018) intervals in the severe PH subgroup with ES were significantly different from the mild PH subgroup, but the JTc interval was not significantly different. Conclusion Despite longer QRS and QTc intervals in the PH group of CHD, JTc interval did not show a significant prolongation.

Electrocardiographic changes in patients undergoing targeted temperature management.

ObjectivesTargeted temperature management is the recommended therapy for comatose patients after an out‐of‐hospital cardiac arrest resuscitation due to the reduction in neurological damage and improved outcomes. However, there may result in electrocardiographic instability depending on the degree of targeted temperature management, including minor or life‐threatening dysrhythmias or conduction delays. This project aims to describe the frequency of ECG interval changes and clinically relevant dysrhythmias in targeted temperature management patients.MethodsThis is a retrospective observational study from January 2009 to December 2015. Patients who qualified for the study had a non‐traumatic cardiac arrest with a return of spontaneous circulation, received targeted temperature management at 33.5°C for 24 hours followed by 16 hours of rewarming. ECG interval changes and dysrhythmias were recorded immediately after return of spontaneous circulation, and at 24 and 48 hours post return of spontaneous circulation.ResultsA total of 322 patients (age 61.0 ± 16.9 years) had targeted temperature management initiated during the study period, of which 169 had complete data and 13 died prior to completing 24 hours of hypothermia. There were statistically significant changes during targeted temperature management in heart rate (96.7 ± 26.0/min before targeted temperature management; 69.5 ± 19.1/min during, P < 0.001), QRS duration (115.1 ± 32.6 ms before targeted temperature management; 107.8 ± 27.9 ms during targeted temperature management, P < 0.001), and QTc (486.3 ± 52.8 ms before targeted temperature management; 526.9 ± 61.7 ms during targeted temperature management, P < 0.001). There were cardiac dysrhythmias that received treatment during cooling and rewarming.ConclusionDuring the period of targeted temperature management and rewarming, we observed few self‐limiting ECG interval changes and no clinically significant dysrhythmias in this population during the period of targeted temperature management.

Evaluation of QRS, QTC, JTC Intervals in Congenital Heart Disease with Pulmonary

BackgroundPulmonary hypertension (PH) in congenital heart disease (CHD) affects the patient prognosis. QRS and QTC intervals prolongation in ECG may exaggerate life-threatening dysrhythmia in these patients. We aimed to investigate the correlation between QRS, QTC and JTC intervals prolongation in ECG with PH in CHD children. Materials and MethodsIn a cross-sectional study that was performed in pediatric cardiology clinic of Besat hospital (Hamadan, Iran), during 2016-2018, patients with CHD and PH as case group (n=40) were compared to simple CHD patients without any evidence of PH as control group (n=40). Based on Pulmonary Artery (PA) to systemic pressure ratio, lower than 1/2 was considered as mild PH and equal and more than 1/2 was considered severe PH; then QRS, QTC, JTC intervals in ECG and RVMPI, TAPSE in echocardiography were compared between case (PH group), and control groups. We also compared these ECG and echocardiographic findings between mild and severe PH group.ResultsThere was significant difference in QRS (p=0.005), and QTC (p=0.036) intervals between two groups, but there was not any significant difference between JTC interval between two groups (p=0.714). Of 40 patients with PH, 19 subjects were in the mild PH group and 21 subjects were in severe PH group, in which nine patients had irreversible PH or Eisenmenger syndrome. QTC (p

Guidelines for reporting case studies and series on drug-induced QT interval prolongation and its complications following acute overdose

Background: The assessment and management of patients with QT interval prolongation in poisoning requires an appropriate method of measuring and adjusting the QT interval for the heart rate (HR) in order to decide if the patient is at risk of life-threatening dysrhythmias, notably torsade de pointes (TdP). As the Clinical Toxicology Collaborative (CTC) workgroup reviewed the published literature on drug-induced QT interval prolongation in poisoning, it became obvious that many publications were missing essential data that were necessary to thoroughly assess and compare the evidence. The aim of this guidance document is to identify essential and ideal criteria required when reporting a case of drug-induced QT interval prolongation and/or TdP in poisoning.Methods: We employed a mixed methods approach as follows. Initially, we reviewed 188 cases of available published case reports and series in the literature regarding drug-induced QT interval prolongation and/or TdP in poisoning as the first step to another project. Common features and deficiencies were identified. Given the large gaps in reporting quality, we conducted an iterative consultative process involving all 23 members of the CTC to identify essential and ideal criteria to analyse publications of QT interval prolongation in poisoning. A priori standards were developed for acceptance or rejection of individual criteria.Results: Survey response was 100%. A minimum set of essential criteria for reporting cases of QT interval prolongation and drug-induced TdP in overdose setting are provided and a 35-item checklist is presented.Conclusions: We report a QT reporting checklist to ensure published case reports and series describing drug-induced QT interval prolongation in poisoning can contribute to the fund of knowledge of QT interval prolongation, TdP and other malignant dysrhythmias.

The differential diagnosis of wide QRS complex tachycardia

Wide complex tachycardia is defined as a cardiac rhythm with a rate greater than 100 beats/min (bpm) and a QRS complex duration greater than 0.10 to 0.12seconds (s) in the adult patient; wide complex tachycardia (WCT) in children is defined according to age-related metrics. The differential diagnosis of the WCT includes ventricular tachycardia and supraventricular tachycardia with aberrant intraventricular conduction, including both relatively benign and life-threatening dysrhythmias. This review focuses on the differential diagnosis of WCT with a discussion of strategies useful in making the appropriate diagnosis, when possible.

Nursing-Based Dysrhythmia Detection on a Dedicated Stroke Unit Using a Unit-Based Cardiac Telemetry Monitoring System.

Acute stroke care includes cardiac rhythm monitoring in the first 24 hours. The method of monitoring varies, as do the reported findings. The nurses' role in this process can be intensive, including primary response and review of all data. Competency is critical as the acute stroke setting can be associated with life-threatening dysrhythmias as well as the detection of atrial fibrillation that affects therapy. Limited studies exist to evaluate the effectiveness of a unit-based cardiac monitoring system for which the bedside nurse has primary responsibility. The goal was to determine if a unit-based cardiac monitoring system for which the bedside nurse was responsible detected clinically significant dysrhythmias. Stroke unit nurses completed a mandatory education program on identifying common dysrhythmias and using the monitoring equipment along with a structured algorithm for cardiac dysrhythmia detection. The nurse was responsible for all alarms as well as review of their patients' data. Their findings were recorded and reviewed by a cardiology team after the 24-hour monitoring was completed. A total of 300 consecutive stokes, transient ischemic attack, and possible stroke patients were enrolled. Nurses identified 96% of all significant dysrhythmias. Twenty-eight percent of the stroke patients had a dysrhythmia, of which 79% were atrial fibrillation/atrial flutter. The bedside nurses did identify all 8 new atrial fibrillation cases. Stroke unit nurses who complete an educational program can identify dysrhythmias on their patients' unit-based cardiac monitoring systems and can improve patient outcomes.

This Is the Year to Listen to Yourself.

This Is the Year to Listen to Yourself.

The Effect of Antiemetics and Antihistamines on the QTc Interval in Emergent Dialysis Patients With Baseline QTc Prolongation

BackgroundUnfunded patients with end-stage renal disease (ESRD) who do not have routinely scheduled hemodialysis often receive medications known to prolong the QTc interval for their uremic symptoms even though they may have pre-existing QTc prolongation. ObjectivesThe purpose of this study was to determine the effects of these medications on the QTc interval in these patients. MethodsUnfunded patients with ESRD presenting to the emergency department (ED) for emergent hemodialysis (HD) with QTc prolongation on their initial electrocardiogram (ECG) were recruited. Approximately 2 hours after receiving an antihistamine or antiemetic, a second ECG was ordered and the QTc was measured. The patients were followed-up 1 week later. ResultsTwenty-nine percent (44/152) of the unfunded patients with ESRD presenting for HD at a county hospital had QT prolongation and were included with 107 total ED visits during the 4-week study period. The mean QTc was 483.7 msec on presentation to the ED, and the mean QTc measured 2 hours after receiving an antihistamine or antiemetic was 483.8 msec. None of the patients were admitted for life-threatening dysrhythmias. Thirty-six percent (16/44) of the recruited patients had QTc intervals >500 msec with a combined total of 31 patient visits, of which only 25.8% (8/31) had an increase in the QTc interval after an antihistamine or antiemetic medication was given. None of these patients had adverse outcomes, such a dysrhythmia or death, at 1-week follow-up. ConclusionThis study shows that medications known to cause QTc prolongation are safe to use in therapeutic doses in patients with ESRD who have pre-existing QT prolongation. Few patients in this cohort had significantly prolonged QTc intervals at baseline.