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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