Slide 1: 60yo M on chronic methadone was treated for PNA with levofloxacin. The next day, became unresponsive. This was his telemetry. [EKG] What is the rhythm?

Slide 2: [EKG] Torsades de Pointes (TdP).

Slide 3: TdP is a polymorphic VT that occurs with prolonged QT. Most commonly, acquired long QTc from medications: antiarrhythmics (Ia, Ic, III), antipsychotics, antidepressants (TCAs, SSRIs), antibiotics (macrolides, fluoroquinolones), antihistamines.

Slide 4: These medications are known to block K+ current in myocytes, prolonging repolarization (QT). Classic initiation of TdP: There’s an ectopic beat -> a pause -> a sinus beat where an early after depolarization (EAD) will fire & trigger TdP.

Slide 5: [EKG shows ectopic beat followed by pause followed by sinus beat w/ long QT followed by EAD on T wave leading to TdP]

Slide 6: Rhythm strip during cardioversion: [EKG]

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