Prolonged QTc and Prevention of Torsades de Pointes Clinical Pathway – Inpatient

Goals and Metrics

Child with Prolonged QTc on 12-Lead Electrocardiogram on Inpatient Unit

Team Assessment

Review:
- VS, physical exam
- Risk Factors/Conditions Associated with Prolonged QT
- Current medications
- Laboratory values (K, Ca, Mg)
- 12-lead ECG for other abnormal findings
Initiate clinical actions based on machine-automated ECG reading

QTc ≥ 470-499 ms
Cardiology Consult Service to review ECG and provide guidance

QTc ≥ 500 ms
Request PHL Cards EP to review ECG and provide guidance

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
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
- Recognition and response to life-threatening alarms remains the responsibility of the primary team
- Non-Cardiac Center (N/IICU, PICU, PCU)
- KOPH (N/IICU, PICU)

Medical Management and Monitoring
Medical Management	Correct modifiable risk factors Electrolyte goals: K+ ≥ 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 to review QTc-prolonging medications Manage medical conditions that increase risk
Monitoring	QTc ≥ 500 ms: Initiate telemetry/supplemental arrhythmia monitoring 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 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

Medical Management and Monitoring

Medical Management

Correct modifiable risk factors
Electrolyte goals:
- K+ ≥ 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 to review QTc-prolonging medications
Manage medical conditions that increase risk

Monitoring

QTc ≥ 500 ms:
- Initiate telemetry/supplemental arrhythmia monitoring
- 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
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
Last Revised: May 2026
Authors:
- C. Srinivasan, MD
- V. Vetter, MD
- N. Bernard, RN
- H. Wolfe, MD
- H. Stinson, MD
- J. Freedman, MD
- B. Homanick, PharmD
Editors: Clinical Pathways Team

Evidence

CHOP Programs

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

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

Evidence

CHOP Programs

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Prolonged QTc and Prevention of Torsades de Pointes Clinical Pathway – Inpatient

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

Evidence

CHOP Programs

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