Bangladesh Crit Care J March 2014; 2 (1): 44-45 Case Summary In May 2012, an 18-year-old lady, with no significant past medical history, got admitted in our ICU with shock and acute abdomen, due to perforation of the gut. All her initial haematological and biochemical results were normal, other than hyponatraemia (133 mmol/L), hypokalaemia (3·3 mmol/L), and raised C-Reactive Protein (404·5 mg/L). No apparent abnormality was noticed on the 12-lead-ECG tracing [Fig.1]. Fig. 1: 12-lead-ECG tracing on admission 1. Ahmad Mursel Anam, MBBS, Chief Resident, ICU. Square Hospitals Ltd. 18/F, BU Qazi Nuruzzaman Sarak, Dhaka 1205, Bangladesh. 2. Raihan Rabbani, FCPS (Medicine), MD(USA), Associate Consultant, ICU & Internal Medicine. Square Hospitals Ltd. 18/F, BU Qazi Nuruzzaman Sarak, Dhaka 1205, Bangladesh. 3. Farzana Shumy, FCPS (Medicine), Medical Officer, Dept. of Internal Medicine. BSM Medical University, Shahbagh, Dhaka 1000, Bangladesh. 4. M Mufizul Islam Polash, MBBS, Clinical Staff, ICU. Square Hospitals Ltd., 18/F, BU Qazi Nuruzzaman Sarak, Dhaka 1205, Bangladesh. 5. M Motiul Islam, MBBS, Clinical Staff, ICU., Square Hospitals Ltd., 18/F, BU Qazi Nuruzzaman Sarak, Dhaka 1205, Bangladesh. 6. ARM Nooruzzaman, MRCP (UK), Consultant, ICU & Internal Medicine., Square Hospitals Ltd., 18/F, BU Qazi Nuruzzaman Sarak, Dhaka 1205, Bangladesh. 7. Mirza Nazim Uddin, MRCP (UK), Consultant, ICU & Internal Medicine., Square Hospitals Ltd., 18/F, BU Qazi Nuruzzaman Sarak, Dhaka 1205, Bangladesh. Corresponding Author : Ahmad Mursel Anam, MBBS, Chief Resident, ICU., Square Hospitals Ltd., 18/F, BU Qazi Nuruzzaman Sarak, Dhaka 1205, Bangladesh. E-mail: murselanam@gmail.com After haemodynamic stabilization, she underwent emergency laparotomy. Jejunostomy and peritoneal toileting was done. She was returned to the ICU for management of hypotension, which was managed accordingly. Post-operatively, excessive secretion from gut started to flow through the jejunostomy. To control the secretion, intravenous infusion of Octreotide was advised. About 24-hours after the infusion started, she suddenly developed hypotension and lost consciousness. Cardiac monitor and rhythm strip tracings showed typical short-long-short ventricular cycle, followed by torsades de pointes (TdP) [Fig.2]. Intravenous magnesium-sulphate was infused and rhythm became sinus. A few minutes later, she again developed TdP, and had a witnessed cardiac arrest, immediately managed with advanced cardiac life support protocol, including DC-cardio-version. Her rhythm became sinus. Fig. 2 : Rhythm strip tracing, showing typical short-long-short ventricular cycle, with premature ventricular contraction (PVC), post-ectopic pause, and abnormal T-wave, leading to classical “twisting of a point” of cardiac axis (torsades de pointes), followed by sinus rhythm after intervention. To identify the cause of the TdP, all her clinical and laboratory findings were re-evaluated, and the corrected QT-interval (QTc) in the first EGC-tracing was found to be 0·536 sec. After checking all possibilities, consensus was reached that, she had acquired Long QT syndrome due to hypokalaemia, which provoked development of TdP after administration of octreotide. The drug was discontinued. Her further stay in hospital and recovery were uneventful. She was discharged in stable condition, with a normal QTc on her ECG. On her follow-up two months later, she was found well and without any complaint. Case Report Prolonged QTc: “Mind the Gap” Ahmad Mursel Anam 1 , Raihan Rabbani 2 , Farzana Shumy 3 , M Mufizul Islam Polash 4 , M Motiul Islam 5 , ARM Nooruzzaman 6 , Mirza Nazim Uddin 7 Abstract We report a case of drug induced torsades de pointes, following acquired long QT syndrome. The patient got admitted for shock with acute abdomen. The initial prolonged QT-interval was missed, and a torsadogenic drug was introduced post-operatively. Patient developed torsades de pointes followed by cardiac arrest. She was managed well and discharged without complications. The clinical manifestations of long QT syndromes, syncope or cardiac arrest, result from torsades de pointes. As syncope or cardiac arrest have more common differential diagnoses, even the symptomatic long QT syndrome are commonly missed or misdiagnosed. In acquired long QT syndrome with no prior suggestive feature, it is not impossible to miss the prolonged QT-interval on the ECG tracing. We share our experience so that the clinicians, especially the junior doctors, will be more alert on checking the QT-interval even in asymptomatic patients. Key Words: QT-interval, Long QT Syndromes, Torsades de Pointes. 44