Inpatient Clinical Pathway for Child with Prolonged QTc
and Prevention of Torsades de Pointes

Goals and Metrics
Inpatient with Prolonged QTc on 12-Lead Electrocardiogram
This pathway provides guidance for consultation, management,
and telemetry monitoring for inpatients with QTc prolongation
FLOC Assessment
  • Review:
  • Initiate clinical actions based on automated ECG reading
    (machine interpretation) pending confirmation by Cardiac EP service
QTc ≥ 470-499 ms
Contact Cardiology Consult service for guidance
QTc ≥ 500 ms
FLOC consult PHL Cards EP service for expeditious confirmation of ECG findings, specifically QTc interval
Hemodynamically Stable
without ventricular
arrhythmia
Hemodynamically Stable
with non-sustained ventricular arrhythmia
  • Non-sustained ventricular tachycardia:
    • ≥ 3 consecutive ventricular beats lasting < 30 sec
  • Frequent ventricular ectopy:
    • > 2 PVCs per 10 sec
    • > 30 per hour
Hemodynamically Unstable
with sustained ventricular tachycardia/torsades de pointes
  • Call Critical Assessment Team (CAT)
  • Consult PHL Cards EP service immediately
  • Call Code Response
  • Consider magnesium sulfate IV
    • 50 mg/kg/dose
      Max dose 2 g/dose
  • Consult PHL Cards EP service immediately
  • Transfer to ICU
Initiate Telemetry/Supplemental Arrhythmia Monitoring
  • Telemetry
    • Real-time alarm response
    • Cardiac Center (CICU, CCU, CPRU, ITCU)
  • Supplemental Arrhythmia Monitoring
    • Intermittent review of non-audible alarms
    • Non-Cardiac Center (N/IICU, PICU, PCU)
Medical Management and Monitoring
Risk Factors/Conditions for Prolonged QTc
  • Correct modifiable risk factors
  • Electrolyte goals:
    • Potassium ≥ 4 mmol/L
    • Magnesium ≥ 2 mg/dL
    • Ionized Calcium ≥ 1.2 mmol/L
  • Correct metabolic acidosis
  • Remove QTc prolonging medications as feasible
  • Consult Clinical Pharmacy as needed
  • Manage medical conditions that increase risk
Monitoring
  • If QTc ≥ 500 ms:
    • Initiate telemetry/supplemental arrhythmia monitoring
    • Add Prolonged QT Interval to problem list
    • Daily ECG after correction of modifiable risk factors or per EP recommendations until QTc remains stable < 500 ms without new risk factors or until steady state of a QTc prolonging medications is expected to have been reached
  • If QTc ≥ 470-499 ms:
    • Repeat ECG after correcting modifiable risk factors
    • Review with Cardiology Consult Service:
      • Further guidance if QTc not improved after medical management
      • Timing of repeat ECGs
      • Follow-up recommendations for all children
Posted: March 2023
Authors: C. Srinivasan, MD; N. Bernard, RN; H. Wolfe, MD; H. Stinson, MD; J. Freedman, MD; V. Vetter, MD