What Do You Do With Long QT?

[docB]

Seems like everyday I get at least one EKG with a long QT. Do you tell the patient about this? Do you have a specific dc instruction (I don't)? I guess if you don't mention it and they drop dead your screwed. Every time I do mention it I get dragged into a long explaination of what it does and doesn't mean. I have the same problem with the "lung nodule" chest xray reads.

---

Members don't see this ad.

 

[GeneralVeers]

Seems like everyday I get at least one EKG with a long QT. Do you tell the patient about this? Do you have a specific dc instruction (I don't)? I guess if you don't mention it and they drop dead your screwed. Every time I do mention it I get dragged into a long explaination of what it does and doesn't mean. I have the same problem with the "lung nodule" chest xray reads.

Long QT may or may not have any significance. I usually don't mention it, because it tends to worry patients, which results in a 10-15 minute conversation just to reassure them. I always tell patients to follow up with their doctor in a week.

 

[USCDiver]

Lung nodules I always tell the patient because they might not followup and then when they get nasty cancer 6months later they blame you.

Long QT can be due to so many different things, including that B-blocker they're always on, so I wouldn't mention it unless there was no other apparent reason.

 

[BADMD]

Seems like everyday I get at least one EKG with a long QT. Do you tell the patient about this? Do you have a specific dc instruction (I don't)? I guess if you don't mention it and they drop dead your screwed. Every time I do mention it I get dragged into a long explaination of what it does and doesn't mean. I have the same problem with the "lung nodule" chest xray reads.

Is it real long QT or computer read long QT? The ECG computers are notoriously bad at calculating the QT interval. The computers often include the chest leads in the average and may not correctly choose the beginning and end of the QT interval. This can be exacerbated by a noisy baseline. If I'm really concerned, I calculate in myself. Calculating out a QTc from there isn't hard. I've been amazed at how many "long QTs" really just go away.

If it is really prolonged and they aren't on any meds that cause prolongation, then yeah, I tell 'em to see their PCP about it.

 

[docB]

Is it real long QT or computer read long QT? The ECG computers are notoriously bad at calculating the QT interval. The computers often include the chest leads in the average and may not correctly choose the beginning and end of the QT interval. This can be exacerbated by a noisy baseline. If I'm really concerned, I calculate in myself. Calculating out a QTc from there isn't hard. I've been amazed at how many "long QTs" really just go away.

If it is really prolonged and they aren't on any meds that cause prolongation, then yeah, I tell 'em to see their PCP about it.

That's a good point. I am just going by the computer calculation. Before you all snicker I don't rely on the machine for my reads but I do use it for the calculation stuff like rates and axes. I suppose I should do the calculation and then I can document that it's not real or actually refer them.

 

[waterski232002]

What about if the patient came in for syncope? Do you admit the patient, or arrange follow up?

 

[docB]

What about if the patient came in for syncope? Do you admit the patient, or arrange follow up?

Another good point. On syncope patients I take it more seriously. I'm thinking (which I didn't make at all clear) about the 4000 random, non-indicated EKGs that get put in front of me for my signature (and assumption of liability) each day.

This is really a separate thread but in my ED the nurses and techs have all been beaten up if anyone doesn't get an EKG in less than 10 minutes of hitting the door. Every one of these EKGs, done before a doc sees these patients, must then be taken to the doc IMMEDIATELY lest a STEMI get missed. The down side is that all kinds of unnecessary EKGs get done. I've seen them for ankle sprains (guy said he felt nauseated from the pain), MVAs, malingering, hip fractures, 20 yo with a cough and essentially everyone over 30. I had to sign one on a guy who couldn't speak English (or Spanish or Tagalog) and showed up at triage. The triage nurse couldn't figure out what his complaint was so she got the EKG to avoid missing the 10 minute window. Once she got the EKG and got me to sign it she went back and got a translator on the phone. The translator figured out that the "patient" hadn't come to the ED. He was just looking for a relative who was an inpatient.

 

[basementbeast]

i think that the 10 min ekg thing is mostly for stemi...therefore clearance from stemi is written as "no 'lytics"....now whenever the patient actually gets seen, that physician should look again (more closely) at the 12 lead...

 

[waterski232002]

I had to sign one on a guy who couldn't speak English (or Spanish or Tagalog) and showed up at triage. The triage nurse couldn't figure out what his complaint was so she got the EKG to avoid missing the 10 minute window. Once she got the EKG and got me to sign it she went back and got a translator on the phone. The translator figured out that the "patient" hadn't come to the ED. He was just looking for a relative who was an inpatient.

That's awesome!

 

[basementbeast]

imagine the cluster if he had BER or something else!!

 

[docB]

i think that the 10 min ekg thing is mostly for stemi...therefore clearance from stemi is written as "no 'lytics"....now whenever the patient actually gets seen, that physician should look again (more closely) at the 12 lead...

True, and that's what we do. I'm pointing out why I get so many EKGs and with the deluge of EKGs, many for dubious indications, all the "abnormal" findings like long QT, RBBB, non-specific T flattening and so on that must be addressed.

 

[basementbeast]

Yep!

 

[basementbeast]

..and asked -> "do you want this patient to go back to the WR for the next 5 hours or do you want them to get a bed?"

 

[Northeaster]

I tell the pt if the QTc is significantly long. In syncope pts I admit if there is a long QTc unless it is a young pt with a clear etiology.

 

[DrQuinn]

I've thought about this a lot over the past year....

Mainly because I've reviewed a case as a med mal defense paralegal of a case of a nurse who came into the ER as a patient for near syncope, had a prolonged QT, was told about it, went home, and died. ? cause of death.

I don't tell patients about it.

If its a prolonged QT and patient is on some crazy med list, I tell them about it, don't add any more medicines, and tell them to call their primary in the AM and refer them to a cardiologist.

If its a prolonged QTc and pt not on any meds and no rsik factors, I do the same as above.

If its a true syncope with prolonged QT(or C), I'll admit them for short stay rule out. Super easy to do where I'm at.

Its a ****ty situation regardless.

DocB, you come up with great siutations for SDN!

Q

 

[waterski232002]

I tell the pt if the QTc is significantly long. In syncope pts I admit if there is a long QTc unless it is a young pt with a clear etiology.

Watch out for discounting Long QT in a young/healthy patient... Congenital Long QT is just as fatal as acquired Long QT (drug related or hypocalcemia induced).

 

[streetdoc]

Lung nodules I always tell the patient because they might not followup and then when they get nasty cancer 6months later they blame you.

Long QT can be due to so many different things, including that B-blocker they're always on, so I wouldn't mention it unless there was no other apparent reason.

I can't find much on B-blockers causing prolonged QT (the exception being sotolol-but due to it's other mechanisms). Am I wrong? just looking to learn...
streetdoc

 

[Jeff698]

This is really a separate thread but in my ED the nurses and techs have all been beaten up if anyone doesn't get an EKG in less than 10 minutes of hitting the door.

Yet another example of how 'metrics' are making a mess out of emergency medicine.

Is it appropriate to get an ECG on chest pain patients as soon as possible? Of course. Is it appropriate, in an effort to achieve the impossible 0% miss rate, of getting ECGs on people walking past the triage desk enroute to the Coke machine? Clearly not but that's the only way you'll ever get to 0%.

We just can't catch 'em all. Perhaps we should focus our efforts on getting better at catching the ones we should reasonably be able to catch.

Take care,
Jeff

 

[ttac]

Is it real long QT or computer read long QT? The ECG computers are notoriously bad at calculating the QT interval. The computers often include the chest leads in the average and may not correctly choose the beginning and end of the QT interval. This can be exacerbated by a noisy baseline. If I'm really concerned, I calculate in myself. Calculating out a QTc from there isn't hard. I've been amazed at how many "long QTs" really just go away.

If it is really prolonged and they aren't on any meds that cause prolongation, then yeah, I tell 'em to see their PCP about it.

Heres a super-nerdy QT article you can use if you ever want to get into a 30 minute discussion with the cards fellow...

summary: Bazetts QT correction (QTc) (QT/square root of RR) was not as accurate as the Fridericia correction:
QT/cube root of RR

which is actually pretty close to the mathematically optimized correction

QT/(RR to the 0.37 power)

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1767027

 

[southerndoc]

We have a prolonged QT instruction set in our Lynx chart system. I usually tell patients about it if it's significant (>500 is what our cardiologists use). I also give them the number of our EP clinic and tell them they have an abnormality on their EKG that could cause them to have an irregular heart rhythm. If they have a history of sudden death in the family or syncope, then I go into much greater detail. If they're there for syncope and they have a prolonged QT, they almost always get admitted and get an EP consult while in house.

 

[jbar]

I know a lot of ECGs get done on patients that may not be indicated by their chief complaint. But one advantage is that when they come back with chest pain a year later we have an old ECG in the computer. Not saying that we should do ECGs of everyone
(though they are fairly cheap, noninvasive, safe etc) Just that there is an upside on not reserving ECGs only for clearly cardiac chest pain.

 

[ttac]

http://www.emedicine.com/MED/topic1983.htm

Very useful/interesting thread. Now another

1. Lets say you have a kid with prolonged QT (the syndrome) who comes in for an unrelated complaint, and you find they have a QTc of 0.55... you treat the unrelated complaint, and are going to discharge them. Do you have to treat the prolonged QT (after correcting their Mg/K)?

Beta-blockers are drugs of choice for patients with LQTS. The protective effect of beta-blockers is related to their adrenergic blockade that diminishes the risk of cardiac arrhythmias. They may also reduce the QT interval in some patients.

Although for years the recommended dosage of beta-blockers was relatively large (eg, propranolol 3 mg/kg/d, or 210 mg/d in a 70-kg individual), recent data suggest that dosages lower than this have a protective effect similar to that of large dosages.

Beta-blockers are effective in preventing cardiac events in approximately 70% of patients, whereas cardiac events continue to occur despite beta-blocker therapy in the remaining 30%.
Propranolol and nadolol are the beta-blockers most frequently used, though atenolol and metoprolol are also prescribed in patients with LQTS. Different beta-blockers demonstrate similar effectiveness in preventing cardiac events in patients with LQTS.

 

[roja]

Document.
Tell them with cardiac type 'd/c' instructions.
Sent them to thier primary doctor.