Nightmare fuel: Clot in transit isn’t moving forwards because the right ventricle is *already* failing and there is a lot of tricuspid regurgitation😩 The term ‘clot in transit’ can be ambiguous because it spans a broad range of disease severity (from small clots to large ones)

This case illustrates common error in the treatment of drug-induced Torsades. A patient presents with drug-induced Torsades, most commonly methadone or dofetilide. They get treated with a bolus of 2-4 grams IV magnesium sulfate and get better. What happens 4-6 hours later? The magnesium wears off (mostly excreted in the urine). Meanwhile, the methadone or dofetilide is still there (it has a much longer half-life than IV magnesium bolus). So the patient has another episode of Torsades. ☠️ I'm tempted to call this an "error" but it's so commonly done that it's basically the standard of care. So perhaps the term "mishap" is more reasonable. Repeat episodes of drug-induced Torsades can be prevented using a protocoled magnesium infusion. We started using this about a decade ago. It's safe and easy to do. It makes these cases really boring. The patient sits around on a Mg infusion for 24 hours allowing Mg to soak into their cardiomyocytes while the methadone/dofetilide levels fall. (#1/2)