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Torsade De Pointes Nursing Guide

Content created/revised by: Alia Lutz, BSN, RN.

Overview: Torsade de Pointes

This content is intended as a Quick Reference for torsades de pointes and will cover an overview as well as nursing considerations utilizing the nursing process.

 

Etiology and Epidemiology

Torsade de pointes (TDP) is a specific polymorphic variation of ventricular tachycardia (VT), also known as TDPVT. TDP can be self-limiting or may evolve into ventricular fibrillation (VF), a life-threatening arrythmia. TDP is also the result of long QT syndrome, which is usually acquired but can be congenital. TDP caused by acquired long QT syndrome is commonly a result of a certain medications (e.g., class Ia, Ic, or III antiarrhythmics) or electrolyte imbalances. TDP caused by congenital long QT syndrome is the result of certain gene mutations, and individuals are more at risk for recurrent syncope due to TDP.

Abnormal functioning of the ion channels and proteins responsible for the ventricular repolarization are the primary causes of QT prolongation leading to TDP. Genetic mutations affect the protein make-up of ion channels that result in long QT syndrome. There are about 15 sub-types of congenital long QT syndrome. Sub-types that fall into long QT syndrome type 1, 2, and 3 cause approximately 90% of these cases (Uvelin et al., 2017).

About 2 to 8% of individuals on class III antiarrhythmic medication are at risk for TDP (Uvelin et al., 2017). However, there are other medications that will put them at risk for TDP, including:

  • Antibiotics (i.e., macrolides or chinolons)
  • Antifungals (ketoconazole [Nizoral®])
  • Antiparasitic (chloroquine [only generics available])
  • Antiemetics (ondansetron [Zofran®, Zuplenz®] or dolasetron [Anzemet®])
  • Analgesics (methadone [Dolophine®, Methadose®] or cocaine)
  • Antihistamines (diphenhydramine [Benadryl®] and terfenadine [Seldane®])
  • Antidepressants (citalopram [Celexa®] or amitriptyline [only generics available])
  • Antipsychotics (haloperidol or thioridazine [only generics available for both])

Other individuals who are most at risk for developing TDP have the following characteristics:

  • Female gender, due to hormones influence on repolarization
  • Older adults
  • Bradycardia
  • Sleep apnea (due to bradycardia)
  • Certain cardiac conditions (i.e., congestive heart failure, myocardial ischemia, left ventricular hypertrophy, or atrioventricular [AV] block)
  • Hypothyroidism
  • Pathologies of the central nervous system (i.e., stroke, epilepsy, or intracranial tumors)

Individuals admitted to the intensive care unit (ICU) appear to have the highest risk for TDP primarily due to electrolyte imbalances or the administration of medications causing long QT prolongation. Rare instances of non-medication induced TDP have occurred, but the incidence is low; between 0.01 to 0.001% (Uvelin et al., 2017).

Diagnosis

An electrocardiography (ECG) is primarily used to diagnose TDP and long QT intervals. Evaluation of long QT syndrome is done by measuring the corrected QT interval (QTc), using the Bazett formula (DynaMed, 2018a):

  • QTc = QT/√RR

The average corrected QT (QTc) interval is (DynaMed, 2018a):

  • Men: Less than 440 milliseconds (ms)
  • Women: Less than 460 ms

For TDP ECG presentation:

  • P waves will be absent.
  • QRS complex will be wide and undulating, with a duration of ≥ 0.12 seconds (Mitchell, 2021a).
    • QRS complexes will also appear to be twisting around the ECG baseline (Mitchell, 2021b).

Management

There are different management options for TDP depending on the presentation and cause:

  • For congenital long QT syndrome to prevent TDP reoccurrence:
    • Beta-blockers
    • Implanted pacemakers
    • Implantable cardioverter defibrillator (ICD)
  • For acquired long QT syndrome:
    • Discontinuation of medication to prevent TDP
  • For recurrent or long runs of TDP:
    • Temporary pacing
    • Intravenous (IV) isoproterenol (Isuprel®), Lidocaine (Xylocaine®) (only generics available), sotalol (Betapace® and Sorine®), or amiodarone (Cordarone® and Pacerone®)
    • Unsynchronized direct-current (DC) cardioversion, starting at 100 joules for acute cases
    • Reverse electrolyte abnormalities:
      • 2 g IV magnesium sulfate (MgSO4®) over 1 to 2 minutes, especially in the presence of hypokalemia (Mitchell, 2021b).
        • If the first administration is unsuccessful, a second bolus of MgSO4 may be given 5 to 10 minutes after the first dose.
        • For renal insufficiency, may need a MgSO4 infusion of 3 to 20 mg/minute.
  • For short-coupled TDP:
    • An implantable cardioverter defibrillator (ICD) may be required, providing there is no structural heart disease present.
  • For TDP “storm” or ICD shock:
    • IV verapamil (Isoptin® and Calan®)
    • Catheter ablation
      • A catheter ablation may also be used for individuals who have TDP induced by premature ventricular complexes (PVCs).

Nursing Considerations

Assessment

Individuals will need to be assessed for (Mitchell, 2021b):

  • Syncope, which is the result of a tachycardic heart rate (HR), between 200 to 250 beats per minute (bpm)
  • The absence of a rapid pulse
  • Low or normal blood pressure (BP)
  • Long QT syndrome

Conscious individuals may report the following signs and symptoms (National Library of Medicine (NLM, 2020):

  • Palpitations
  • Angina
  • Shortness of breath
  • Lightheadedness/dizziness

Individuals with TDP may also be hemodynamically unstable.

Nursing Diagnosis/Risk For

  • Electrolyte imbalances, as evidenced by (Uvelin et al., 2017):
    • Persistent vomiting
  • Falls, as evidenced by:
    • Lightheadedness
    • Dizziness
  • Fainting, as evidenced by:
    • Rapid pulse (200 to 250 bpm)
    • Low blood pressure
    • Low oxygen saturations
  • Ventricular fibrillation (VF), as evidenced by:
    • Sustained TDP, which can evolve into VF
  • Asystole, as evidenced by:
    • VF, which can quickly lead to asystole if not treated promptly

Individuals with untreated TDP are at risk for recurrent syncope, the development of VF, and ultimately death. That is why TDP should be considered a medical emergency, and swift action must be taken to reverse it, especially if TDP is frequent or prolonged.

Interventions

  • Use continuous ECG monitoring via telemetry for individuals with long QT syndrome at risk for TDP.
  • Monitor vital signs frequently for hemodynamic instability, based on institutional policies.
  • Administer IV medication, per clinician orders.
  • Monitor serum potassium and magnesium blood levels for electrolyte imbalances.
  • Initiate falls protocol for at risk individuals.
  • Initiate cardiopulmonary resuscitation (CPR) if TDP is sustained, and the individual is unconscious.

Expected Outcomes

  • Serum potassium and magnesium levels return to normal.
  • There is a return to hemodynamic stability.
  • The individual is able to verbalize the resolution of symptoms (i.e., lightheadedness, palpitations, or shortness of breath).
  • Resolution of prolonged QT intervals seen on ECG.

Patient/Caregiver Education

  • Review risk factors for long QT syndrome and TDP:
    • Certain medications
    • Strenuous exercise (for congenital long QT syndrome)
  • Review importance of screening for congenital long QT syndrome:
    • ECG evaluation for family members
  • Review signs and symptoms associated with arrhythmias and when to seek immediate medical treatment:
    • Shortness of breath
    • Palpitations
    • Fainting
    • Chest discomfort
    • Exercise intolerance
  • Review what to do when signs and symptoms occur:
    • How to check pulse
    • Importance of lying down if dizzy or lightheaded
    • Techniques to attempt when HR is tachycardic
  • Review medications:
    • What medications to avoid, and the importance of checking which over-the-counter (OTC) medications, supplements, or cold and allergy medications should be avoided
    • The importance of medication adherence
  • Review procedures for catheter ablation and implantation of pacemaker and/or ICD:
    • How and why procedures are done
    • Importance of carrying a medical device identification (ID) card
  • Review the importance of regular follow-up with the individual’s primary care physician to screen for long QT syndrome and TDP (National Heart, Lung, and Blood Institute, n.d.)

 

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Fatal Heart Rhythms CE Course

This course reviews fatal heart rhythms, including ventricular fibrillation (VFib), ventricular tachycardia (VT), Torsades de pointes (TdP), asystole, and pulseless electrical activity (PEA).
0.25 Contact Hours

Additional Information

Content Release Date 

4/1/2022

Content Expiration

12/31/2028

Content Contributor

The content was created/revised by Alia Lutz, BSN, RN.

Alia Lutz, BSN, RN, has over 10 years of experience as a Registered Nurse with a focus on cardiothoracic, respiratory, and coronary care. She has also had experience in med-surg, step-down, and ICU. Prior to joining Relias as a SME and Content Writer for acute care, she provided virtual education and injection training on injectable biologics to patients, reported adverse events, and was a patient advocate. She has collaborated with peers on creating job aids, writing policies, and improving quality of care and documentation. Alia received her bachelor's in nursing from Otago Polytechnic in New Zealand in 2011.

References

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