November 01, 2023

Episode 190: Electrical Storm

10 minutes

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

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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)

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.

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