Management of hemodynamically stable wide QRS complex tachycardia in patients with implantable cardioverter defibrillators.

Management of hemodynamically stable, incessant wide QRS complex tachycardia (WCT) in patients who already have an implantable cardioverter defibrillator (ICD) is challenging. First-line treatment is performed by medical staff who have no knowledge on programmed ICD therapy settings and there is always some concern for unexpected ICD shock. In these patients, a structured approach is necessary from presentation to therapy. The present review provides a systematic approach in four distinct phases to guide any physician involved in the management of these patients: PHASE I: assessment of hemodynamic status and use of the magnet to temporarily suspend ICD therapies, especially shocks; identification of possible arrhythmia triggers; risk stratification in case of electrical storm (ES). PHASE II: The preparation phase includes reversal of potential arrhythmia "triggers", mild patient sedation, and patient monitoring for therapy delivery. Based on resource availability and competences, the most adequate therapeutic approach is chosen. This choice depends on whether a device specialist is readily available or not. In the case of ES in a "high-risk" patient an accelerated patient management protocol is advocated, which considers urgent ventricular tachycardia transcatheter ablation with or without mechanical cardiocirculatory support. PHASE III: Therapeutic phase is based on the use of intravenous anti-arrhythmic drugs mostly indicated in this clinical context are presented. Device interrogation is very important in this phase when sustained monomorphic VT diagnosis is confirmed, then ICD ATP algorithms, based on underlying VT cycle length, are proposed. In high-risk patients with intractable ES, intensive patient management considers MCS and transcatheter ablation. PHASE IV: The patient is hospitalized for further diagnostics and management aimed at preventing arrhythmia recurrences.

A case of ulceroglandular tularemia presenting with lymphadenopathy and an ulcer on a linear morphoea lesion surrounded by erysipelas.

Tularemia is a zoonosis caused by the infection of Francisella tularensis (a gram-negative aerobic bacterium). Transmission to other animals or humans usually occurs through insect or tick bites, direct contact with a contaminated environment (mud or water), infected animals - mainly lagomorphs - or by ingesting undercooked meat or inhaling contaminated dust (hay or soil). This paper discusses the case of a 32-year-old man, who came to our Emergency Room presenting with persistent fever, inguinal lymphadenopathy, and an ulcer on his left lower limb on a linear morphoea lesion that had been there for some time. The lesion was surrounded by erysipelas. After hospitalization and tests, the patient was diagnosed with ulceroglandular tularemia. Antibiotic treatment with doxycycline resolved the clinical picture, but not the morphoea lesion.