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PODCAST: Electrical Storm

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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.

                                • The post PODCAST: Electrical Storm first appeared on האיגוד הישראלי לרפואה דחופה.

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