No not this electrical storm
One of the picks in R&R in the fast lane a few weeks back.
A few brief points:
- Electrical storm defined as:
- 3 or more sustained episodes of ventricular tachycardia (VT), ventricular fibrillation (VF), or appropriate implantable cardioverter-defibrillator (ICD) shocks during a 24-hour period
- sympathetic output is a big thing driving this and therefore adrenaline is probably a really bad idea in these people (which is a shame because it’s often used as a first line drug when they lose their pulse from VF…)
- they suggest using beta blockers (particularly propanolol, though I think if I ever do this I’ll be reaching for the esmolol instead) as the key agent in treating it
- some people have even used stellate ganglion (the source of sympathetic outflow to the thorax) block as a treatment for electrical storm
- they also push amiodarone as a useful drug in this context and while I know it has the guidelines behind it I’ve heard a lot of other people say procainamide is the way to go. Any thoughts?
I’m not sure if this works as an analogy but when thinking about the difference between monomorphic and polymorphic VT then I think of them as similar focal seizures and generalised seizures:
- in monomorphic VT there is one focal point of re-entry, usually a scar from an old MI. In focal seizures there is often a scar point, either from tumour or from an old head injury
- in polymorphic VT there are multiple “wavefronts” that must propagate throughout the heart; hence the fluctuating ECG. Similar to a generalised seizure where the EEG is widely chaotic.
This may be entirely wrong so please let me know if it is. In any case I think this review has helped get a lot of the core concepts finally secured in my brain.
Eifling M, Razavi M, Massumi A. The evaluation and management of electrical storm. Tex Heart Inst J 2011;38(2):111–121. PMC3066819 (free full text)
- Electrical Storm: LITFL
- Resus Review — Ultrasound Guided Stellate Ganglion Block for Refractory Ventricular Fibrillation
- Nademanee, K, R Taylor, W E Bailey, D E Rieders, and E M Kosar. “Treating Electrical Storm : Sympathetic Blockade Versus Advanced Cardiac Life Support-Guided Therapy.” Circulation 102, no. 7 (August 15, 2000): 742–747. doi:10.1161/01.CIR.102.7.742.
Incessant ventricular tachycardia can indeed be a very difficult to treat, While ACLS guidelines recommend Class I antiarrhythmics, the underlying problem is excessive sympathetic activity and there fore beta blockade is the treatment of choice. Small doses of metoprolol IV, or my preferred medication, an esmolol infusion. A stellate ganglion block can be attempted in salvage cases. However, in practice it is not uncommon for the patient to have already received amiodarone and lidocaine also.
Hi Charles, thanks for the comment and your posts on this, I found them really useful. I note the Nademanee paper was done in the era pre-amiodarone and wondered if that would make much of a difference?
Agree totally – I’d reach for the esmolol, due to availability and familiarity.