Title:
"Twist of Fate?"
Complexity Level:
🟠
A 32-year-old woman with a history of diabetes mellitus presents to the Emergency Department with blood glucose levels exceeding 400 mg/dL. She also reports experiencing atypical chest pain.
While being monitored in the ED, her telemetry shows intermittent episodes of wide QRS complexes at a rapid rate.
What's the most appropriate next step?
1
Comments (2)
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Correct answer is A. Explanation in video below.
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Why this tracing is not Torsade de Pointes
Since most people (over 60%) voted to treat this as torsade, it’s worth clarifying why this is actually artifact rather than a true arrhythmia. The strip mimics polymorphic VT, but several key features are missing:
- Lack of typical initiation pattern
- At the red arrow in the above image, you can see the beat just before the “tachycardia” starts. Torsade almost always begins after a pause (pause-dependent) or on the background of bradycardia.
- Here, there is no preceding pause or classic “short–long–short” sequence that would set up torsade.
- No QT prolongation
- For torsade to occur, there should be baseline QT prolongation—at least in the initiating beat, if not throughout.
- The beats leading into this episode do not show prolonged repolarization.
✅ Teaching point:
Because artifact can mimic polymorphic VT, many clinicians may mistake it for torsade. Recognizing the absence of QT prolongation and the lack of pause-dependent initiation at the red arrow is key.
📌 One-liner takeaway:
If there’s no pause and no QT prolongation at initiation (red arrow), it’s likely not torsade.