TIGER, tiger, burning bright
|In the forests of the night,|
|What immortal hand or eye|
|Could frame thy fearful symmetry?|
She was a strange lady: the triage nurse visibly rolled her eyes as she gave me report. "Seizures" 20 times a day for weeks. Strange auras. A poor and unreliable historian. She was a a heavy drinker with unspecified mental health problems. She'd had one of her "episodes" at triage and it had looked pretty fake -- certainly not an epileptic-type seizure. It did not sound like a promising case, at least not in the sense of finding a "real" diagnosis or a productive treatment plan.
Until the patient arrested, of course. That got our attention pretty quick! She had just been put on the monitor, and the nurse happened to be in the room and saw her go out. We called the code, and hooked up the machines and gave her the good juice, which fixed her. For the moment.
This is what the monitor showed:
Uploaded with Skitch!
Is that not beautiful? This is Torsades de Pointes, an arrhythmia which is a sub-type of ventricular tachycardia in which the QRS axis twists around the myocardium. It's linked to long QT syndrome and low magnesium. You can see in the above image how symmetric and regular the pattern is as the electrical focus moves around the heart.
There's not much more to the story: This lady, once we converted her back into sinus, has a corrected QT interval somewhere around 600ms! It was likely related to a medication she was taking. She wound up going back into torsades about three times, requiring recurrent cardioversion, before the Mag and lido kicked in and stabilized her rhythm.
If there's a point to the story, I suppose it's that even weird/crazy patients have bad things happen to them and you can never assume someone is just nuts. But mostly I wanted to share a lovely picture.