Table 5.

Management of Torsade des Pointes (TdP).

• Intravenous administration of 2 g magnesium sulfate (MgSO4)*

• Isoproterenol infusion to increase the heart rate until a temporary pacemaker wire is inserted†

• Overdrive temporary pacing at 90–110 bpm

• Direct current (DC) cardioversion if TdP has degenerated into ventricular fibrillation (VF)

• Promptly halt offending agent(s) / correct electrolyte abnormalities

^⁎This dose may be repeated, if needed, at 5-15 min. Alternatively, an infusion of 1-4 gm/h may be started to keep the magnesium levels >2 mmol/L. Once the magnesium level reaches ~ 3 mmol/L, the infusion can be stopped to avoid toxicity noted with levels >3.5 mmol/L. Serum potassium should be maintained at 4.5-5 mmol/L.

^†Isoproterenol is given at an infusion rate of 1-4 μg/min titrated to maintain a heart rate of ~100 bpm. Isoproterenol is, however, contraindicated in patients with congenital LQTS, as it may paradoxically prolong the QT interval.