Episode 190: Electrical Storm

We discuss Electrical Storm (VT storm) and how to care for the very irritable heart. Hosts: Brian Gilberti, MD Reed Colling, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Electrical_Storm.mp3 Download Leave a Comment Tags: Cardiology Show Notes Background/Overview of VT: Definition: What makes it a storm  Three or more sustained episodes of VF, VT, or appropriate ICD shocks in a 24-hour period Pathophysiology: Understanding the origin and mechanism Sympathetic drive/adrenergic surge Underlying pathology: Sodium channelopathies, infiltrative disease like cardiac sarcoidosis, etc. RF’s / trigger / population (reversible cause in ~25% of patients) MI Electrolyte Derangements (emphasis on potassium and magnesium) New/worsening heart failure Catecholamine Surge Drugs (stimulants, cocaine, amphetamines, etc) QT Prolongation Thyrotoxicosis Clinical Presentation: Symptoms of VT: spectrum of symptoms – from palpitations to syncope to cardiac arrest Differentiating VT from other potential ER presentations. Diagnostics in ER: Electrocardiogram (ECG): Recognizing VT patterns. Monomorphic vs polymorphic (Torsades) may change management Wide QRS Fusion best Capture beats Concordance  AV-dissociation Lab tests: Potassium, magnesium, troponins, TFTs, etc. Acute Management in the ER: Hemodynamically stable vs. unstable V Unstable = cardioversion Sedation Catecholamine surge should be considered  No ideal agent  Etomidate or propofol can be considered  Ketamine may worsen irritability  Pharmacological treatments: Amiodarone Class III antiarrhythmic  Most studied in VT storm  First line Beta Blockers Propranolol B1 and B2 activity  Non-pharmacological approaches: Immediate synchronized cardioversion IABP / ECMO considered for HD unstable patient Cath lab if ischemic etiology suspected  Stellate Ganglion Block Take Home Points Definition: VT Storm is commonly defined as three or more sustained episodes of ventricular fibrillation, ventricular tachycardia, or appropriate ICD shocks within a 24-hour period. Varied Presentation: Patients may experience a range of symptoms from palpitations to severe hemodynamic instability. ECG and Diagnosis: Initial ECG may not show VT; continuous cardiac monitoring or device interrogation may be required for diagnosis. VT Identification: Look for wide QRS, rate over 100, fusion beats, capture beats, and AV dissociation to identify VT. Management in Hemodynamic Instability: Cardiovert if the patient shows signs of hemodynamic instability. Sedation Considerations: Be cautious with sedation, especially with ketamine, as it may worsen cardiac irritability in these already adrenergic state patients. Medication Choices: Typically, amiodarone and propranolol are used to manage VT Storm. Cardiology Involvement: Involve cardiology early on, as treatment may extend beyond medications. Read More