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This study aimed to identify which patients with severe QTc prolongation on presentation to the emergency department (ED) after overdose will develop ventricular dysrhythmias, death, cardiac arrest, the need for rhythm control, or extracorporeal membrane oxygenation utilization.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>Secondary analysis of Toxicology Investigators Consortium Core Registry data from 2013 to 2023. We included patients \u2265\u200913\u2009years old with acute or acute\u2010on\u2010chronic overdose, toxicology consultation in the inpatient or ED setting, and initial ED electrocardiogram QTc \u2265\u2009500\u2009ms. We excluded patients with no or unknown toxicologic exposure, symptoms unlikely or unknown whether related to exposure, or missing data. The primary outcome was ventricular dysrhythmia. Secondary outcomes included death, cardiac arrest, rhythm control, and extracorporeal membrane oxygenation. Independent variables included patient and overdose characteristics, initial QTc and bicarbonate values, clinical findings, and drug exposures. Multivariable logistic regression was performed with ventricular dysrhythmia as the dependent variable to identify potential predictors. Diagnostic test characteristics were calculated for risk factors identified in the regression model.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Of 2764 patients screened, 1265 were included. Forty\u2010eight (3.79%) patients developed ventricular dysrhythmias. Bradycardia (aOR 3.12, 95% CI 1.35\u20136.90), acidosis (aOR 3.02, 95% CI 1.42\u20136.23), and shock (aOR 4.54, 95% CI 2.07\u20139.75) were independently associated with ventricular dysrhythmia on regression analysis and were each associated with every secondary outcome. The absence of any of these findings had a negative predictive value of 98.2% (97.2%\u201398.9%) for developing ventricular dysrhythmia.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>In this large international data registry, we identified predictors of ventricular dysrhythmia in patients presenting to the ED after overdose in the setting of severe QTc prolongation.<\/jats:p><\/jats:sec>","DOI":"10.1111\/acem.70083","type":"journal-article","created":{"date-parts":[[2025,6,10]],"date-time":"2025-06-10T05:51:47Z","timestamp":1749534707000},"page":"1065-1075","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Clinical Factors Associated With Ventricular Dysrhythmia in Emergency Department Patients With Severe QTc Prolongation After Drug Overdose"],"prefix":"10.1111","volume":"32","author":[{"given":"Michael D.","family":"Simpson","sequence":"first","affiliation":[{"name":"Department of Emergency Medicine, Beth Israel Deaconess Medical Center Harvard Medical School  Boston Massachusetts USA"},{"name":"Massachusetts and Rhode Island Poison Center  Boston Massachusetts USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Katherine B.","family":"Tang","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, Beth Israel Deaconess Medical Center Harvard Medical School  Boston Massachusetts USA"},{"name":"Massachusetts and Rhode Island Poison Center  Boston Massachusetts USA"},{"name":"Harvard Medical Toxicology, Division of Emergency Medicine Boston Children's Hospital  Boston Massachusetts USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael W.","family":"Donnino","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, Beth Israel Deaconess Medical Center Harvard Medical School  Boston Massachusetts USA"},{"name":"Department of Medicine, Division of Pulmonary and Critical Care Beth Israel Deaconess Medical Center  Boston Massachusetts USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peter R.","family":"Chai","sequence":"additional","affiliation":[{"name":"Massachusetts and Rhode Island Poison Center  Boston Massachusetts USA"},{"name":"Department of Emergency Medicine Brigham and Women's Hospital  Boston Massachusetts USA"},{"name":"The Fenway Institute, Fenway Health  Boston Massachusetts USA"},{"name":"Department of Psychosocial Oncology and Palliative Care Dana Farber Cancer Institute  Boston Massachusetts USA"},{"name":"The Koch Institute for Integrated Cancer Research, Massachusetts Institute of Technology  Boston Massachusetts USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rachel","family":"Culbreth","sequence":"additional","affiliation":[{"name":"American College of Medical Toxicology  Phoenix Arizona USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sharan","family":"Campleman","sequence":"additional","affiliation":[{"name":"American College of Medical Toxicology  Phoenix Arizona USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paul","family":"Wax","sequence":"additional","affiliation":[{"name":"American College of Medical Toxicology  Phoenix Arizona USA"},{"name":"University of Texas Southwestern Medical Center  Dallas Texas USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alex F.","family":"Manini","sequence":"additional","affiliation":[{"name":"Center for Research on Emerging Substances, Poisoning, Overdose, and New Discoveries Icahn School of Medicine at Mount Sinai  New York New York USA"},{"name":"New York City Health + Hospitals\/Elmhurst  New York New York USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michele M.","family":"Burns","sequence":"additional","affiliation":[{"name":"Massachusetts and Rhode Island Poison Center  Boston Massachusetts USA"},{"name":"Harvard Medical Toxicology, Division of Emergency Medicine Boston Children's Hospital  Boston Massachusetts USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"name":"the Toxicology Investigators Consortium","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2025,6,10]]},"reference":[{"key":"e_1_2_11_2_1","volume-title":"Drug Overdose Surveillance and Epidemiology (DOSE) System","author":"Centers for Disease Control and Prevention","year":"2024"},{"key":"e_1_2_11_3_1","doi-asserted-by":"publisher","DOI":"10.1080\/15563650.2023.2268981"},{"key":"e_1_2_11_4_1","unstructured":"European Monitoring Centre for Drugs and Drug Addiction European Drug Report 2023: Trends and Developments(2023) 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