Episode 190: Electrical Storm

We discuss Electrical Storm (VT storm) and how to care for the very irritable heart.

Brian Gilberti, MD
Reed Colling, MD

November 1st, 2023 Download Leave a Comment Tags:

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.

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