Electrical storm
Background
- Definition: 3 or more episodes of sustained ventricular tachycardia, ventricular fibrilation, or ICD shocks within 24 hours
- Type 2 Diabetes is protective
Risk factors [1]
- CAD
- HFrEF
- QT prolongation
Causes
- Ischemia
- Electrolyte derangement
- Iatrogenic (i.e. QT prolonging medications)
- Hyperthyroidism
- Infection/Fever
- Brugada syndrome
- Short QT syndrome, long QT syndrome
- Early repolarization syndrome, especially in inferior leads
Clinical Features
- Presentation as:
- Cardiac arrest
- Palpitations
- (Pre)Syncope
- ICD patient complaining of shock(s)
Differential Diagnosis
Wide-complex tachycardia
Assume any wide-complex tachycardia is ventricular tachycardia until proven otherwise (it is safer to incorrectly assume a ventricular dysrhythmia than supraventricular tachycardia with abberancy)
- Regular
- Monomorphic ventricular tachycardia
- PSVT with aberrant conduction:
- PSVT with bundle branch block^
- PSVT with accessory pathway
- Atrial flutter with bundle branch block^
- Sinus tachycardia with bundle branch block^
- Accelerated idioventricular rhythm (consider if less than or ~120 bpm)
- Metabolic
- Irregular
- Atrial fibrillation/atrial flutter with variable AV conduction AND bundle branch block^
- Atrial fibrillation/atrial flutter with variable AV conduction AND accessory pathway (e.g. WPW)
- Atrial fibrillation + hyperkalemia
- Polymorphic ventricular tachycardia
^Fixed or rate-related
ICD malfunction
- A fib/SVT
- Oversensing
- Lead fracture
Evaluation
- ECG or clinical history for those with ICDs
Management
Emergency Department
- Follow current ACLS guidelines if pulseless
- Analgesia / sedation for all patients
- ACC recommends repletion of K to 4.5 in all cases [2]
- Amiodarone 1st line antiarrhythmic (preferred over lidocaine) for most cases[3]
- Efficacy of lidocaine highest if actively ischemic
- Beta blockade: Minimize epinephrine use as much as possible
- Consider sympathetic blockade as first line over ACLS antiarrhythmics
- Especially in patients that are high risk CAD
- 67% vs. 5% survival in 49 patient study, respectively for esmolol/propranolol vs. ACLS antiarrhythmic[4]
- Patients who survived initial ES event did well over 1 yr follow up
- Metoprolol 2.5-5mg IV q2-5 min to max of 15mg
- Propranolol 0.15mg/kg IV over 10 minutes followed by 3-5mg q6h; may be effective even if metoprolol fails
- More efficacious than metoprolol, terminated VT at 3 hours vs. 18 hours with metoprolol [5]
- Esmolol 300-500 mcg/kg load over 1 minutes follwed by infusion at 25-50 mcg/kg/min initial dose
- Consider sympathetic blockade as first line over ACLS antiarrhythmics
- Exceptions to above are:
- Torsades with known long QT
- Magnesium sulfate 1-2 grams IV over 1-2 minutes
- Potassium repletion
- If bradycardic between episodes, pace at 90-120 or start Isoproterenol 2 mcg/min and titrate to HR 90-100
- Consider bolus dose 0.02-0.06mg isoproterenol, then infusion
- Brugada syndrome[6]
- Isoproterenol infusion is 1st line
- Quinidine may be of benefit[7]
- Due to it's Ito channel blockade
- Sodium channel blockade may be harmful, however (avoid other Class I antiarrhythmics)
- Torsades with known long QT
- Consider isoproterenol in electrical storm in the following situations:
- Recalcitrant idiopathic ventricular fibrillation, not associated with structural heart, electrical, coronary heart disease
- Benign early repolarization with J waves[8]
- Idiopathic ventricular fibrillation with complete right bundle branch block
- Consider isoproterenol carefully as it has been used to induce ventricular tachycardia by EPs[9]
Disposition
- Admit
External Links
References
- Brigadeau F et al. Clinical predictors and prognostic significance of electrical storm in patients with implantable cardioverter defibrillators. Eur Heart J 2006;27:700-7.
- Zipes DP et al. ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death. J Am Coll Card 2006;48(5):e247-346.
- Eifling M, Ravazi M, Massumi A. The Evaluation and Management of Electrical Storm. Tex Heart Inst J 2011;38(2):111-21
- Nademanee K et al. Treating Electrical Storm: Sympathetic Blockade Versus Advanced Cardiac Life Support–Guided Therapy. Circulation. 2000; 102: 742-747.
- Chatzidou, S., Kontogiannis, C., Tsilimigras, D. I., Georgiopoulos, G., Kosmopoulos, M., Papadopoulou, E., … Rokas, S. (2018). Propranolol Versus Metoprolol for Treatment of Electrical Storm in Patients With Implantable Cardioverter-Defibrillator. Journal of the American College of Cardiology, 71(17), 1897–1906.
- Jongman JK et al. Electrical storms in Brugada syndrome successfully treated with isoproterenol infusion and quinidine orally. Neth Heart J. 2007 Apr; 15(4): 151–155.
- Belhassen B et al. Efficacy of Quinidine in High-Risk Patients With Brugada Syndrome. Circulation. 2004; 110: 1731-1737.
- Aizawa Y et al. Electrical storm in idiopathic ventricular fibrillation is associated with early repolarization. J of Am Coll of Card. Vol 62, No 11, 2013.
- de Meester A et al. Usefulness of isoproterenol in the induction of clinical sustained ventricular tachycardia during electrophysiological study. Acta Cardiol. 1997;52(1):67-74.
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