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)
  
  • 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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