Electrical storm: Difference between revisions
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==Background== | ==Background== | ||
*Definition | *Definition: 3 or more episodes of sustained [[ventricular tachycardia]], [[ventricular fibrilation]], or ICD shocks within 24 hours | ||
*Most have underlying structural heart disease, but also seen in those with structurally normal hearts (i.e. [[Brugada syndrome]], [[Long QT syndrome]]) | |||
*Type 2 Diabetes is protective | |||
===Risk factors <ref> 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. </ref>=== | ===Risk factors <ref> 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. </ref>=== | ||
*CAD | *CAD | ||
*HFrEF | *HFrEF | ||
*[[ | *[[QT prolongation]] | ||
===Causes=== | ===Causes=== | ||
| Line 15: | Line 15: | ||
*[[Hyperthyroidism]] | *[[Hyperthyroidism]] | ||
*Infection/[[Fever]] | *Infection/[[Fever]] | ||
*[[Brugada syndrome]] | |||
*[[Short QT syndrome]], [[long QT syndrome]] | |||
*[[Early repolarization syndrome]], especially in inferior leads | |||
==Clinical Features== | ==Clinical Features== | ||
| Line 22: | Line 25: | ||
**(Pre)[[Syncope]] | **(Pre)[[Syncope]] | ||
**ICD patient complaining of shock(s) | **ICD patient complaining of shock(s) | ||
*Type of Ventricular Arrhythmias <ref>Credner SC, Klingenheben T, Mauss O, et al. Electrical storm in patients with transvenous implantable cardioverter-defibrillators: incidence, management and prognostic implications. J Am Coll Cardiol 1998; 32:1909</ref> <ref>Hohnloser SH, Al-Khalidi HR, Pratt CM, et al. Electrical storm in patients with an implantable defibrillator: incidence, features, and preventive therapy: insights from a randomized trial. Eur Heart J 2006; 27:3027</ref> | |||
**Monomorphic VT 86-97% | |||
**Primary VF 1-21% | |||
**Mixed VT/VF 3-14% | |||
**Polymorphic VT 2-8% | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
| Line 30: | Line 39: | ||
*Lead fracture | *Lead fracture | ||
== | ==Evaluation== | ||
*[[ECG]] or clinical history for those with ICDs | *[[ECG]] or clinical history for those with ICDs | ||
==Management== | ==Management== | ||
===Emergency Department=== | ===Emergency Department=== | ||
*Follow current ACLS guidelines if pulseless | *Follow current ACLS guidelines if pulseless | ||
**See [[Adult Pulseless Arrest]] | **See [[Adult Pulseless Arrest]] | ||
*Analgesia / | *[[Analgesia]] / [[sedation]] for all patients | ||
*ACC recommends repletion of K to 4.5 in all cases <ref name="ACC SCD"> 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. </ref> | *ACC recommends repletion of K to 4.5 in all cases <ref name="ACC SCD"> 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. </ref> | ||
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**Consider '''sympathetic blockade as first line''' over ACLS antiarrhythmics | **Consider '''sympathetic blockade as first line''' over ACLS antiarrhythmics | ||
***Especially in patients that are high risk CAD | ***Especially in patients that are high risk CAD | ||
***67% vs. 5% survival in 49 | ***67% vs. 5% survival in 49 patient study, respectively for esmolol/propranolol vs. ACLS antiarrhythmic<ref>Nademanee K et al. Treating Electrical Storm: Sympathetic Blockade Versus Advanced Cardiac Life Support–Guided Therapy. Circulation. 2000; 102: 742-747.</ref> | ||
*** | ***Patients who survived initial ES event did well over 1 yr follow up | ||
**[[Metoprolol]] 2.5- | **[[Metoprolol]] 2.5-5mg IV q2-5 min to max of 15mg | ||
**[[Propranolol]] 0. | **[[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 <ref> 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.</ref> | |||
**[[Esmolol]] 300-500 mcg/kg load over 1 minutes follwed by infusion at 25-50 mcg/kg/min initial dose | **[[Esmolol]] 300-500 mcg/kg load over 1 minutes follwed by infusion at 25-50 mcg/kg/min initial dose | ||
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***Potassium repletion | ***Potassium repletion | ||
***If bradycardic between episodes, pace at 90-120 or start [[Isoproterenol]] 2 mcg/min and titrate to HR 90-100 | ***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. | ***Consider bolus dose 0.02-0.06mg isoproterenol, then infusion | ||
**[[Brugada syndrome]]<ref>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.</ref> | **[[Brugada syndrome]]<ref>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.</ref> | ||
***[[Isoproterenol]] infusion is 1st line | ***[[Isoproterenol]] infusion is 1st line | ||
***Quinidine may be of benefit | ***[[Quinidine]] may be of benefit<ref>Belhassen B et al. Efficacy of Quinidine in High-Risk Patients With Brugada Syndrome. Circulation. 2004; 110: 1731-1737.</ref> | ||
****Due to | ****Due to its Ito channel blockade | ||
****Sodium channel blockade may be harmful, however (avoid other Class I antiarrhythmics) | ****Sodium channel blockade may be harmful, however (avoid other Class I antiarrhythmics) | ||
*Consider [[isoproterenol]] in electrical storm in the following situations: | *Consider [[isoproterenol]] in electrical storm in the following situations: | ||
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*Ablation | *Ablation | ||
*Left sympathetic ganglionic blockade | *Left sympathetic ganglionic blockade | ||
*Deep sedation / general anesthesia | *Deep [[sedation]] / general anesthesia | ||
*IABP / ECMO | *IABP / [[ECMO]] | ||
*Palliative care as this could represent | *[[Palliative care]] as this could represent impending terminal failure | ||
==Disposition== | ==Disposition== | ||
* | *Admit | ||
==See Also== | ==See Also== | ||
*[[Torsades de pointes]] | *[[Torsades de pointes]] | ||
*[[ | *[[Wide-complex tachycardia]] | ||
*[[Adult pulseless arrest]] | *[[Adult pulseless arrest]] | ||
==External Links== | ==External Links== | ||
*[https://first10em.com/electrical-storm/ First10EM - Management of Electrical Storm] | |||
*[https://emottawablog.com/2020/05/braving-the-electrical-storm-in-the-ed/ EM Ottawa - Braving the Electrical Storm in the ED] | |||
==References== | ==References== | ||
Latest revision as of 00:48, 2 July 2021
Background
- Definition: 3 or more episodes of sustained ventricular tachycardia, ventricular fibrilation, or ICD shocks within 24 hours
- Most have underlying structural heart disease, but also seen in those with structurally normal hearts (i.e. Brugada syndrome, Long QT syndrome)
- 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)
- Type of Ventricular Arrhythmias [2] [3]
- Monomorphic VT 86-97%
- Primary VF 1-21%
- Mixed VT/VF 3-14%
- Polymorphic VT 2-8%
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
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 [4]
- Amiodarone 1st line antiarrhythmic (preferred over lidocaine) for most cases[5]
- 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[6]
- 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 [7]
- 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[8]
- Isoproterenol infusion is 1st line
- Quinidine may be of benefit[9]
- Due to its 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[10]
- Idiopathic ventricular fibrillation with complete right bundle branch block
- Consider isoproterenol carefully as it has been used to induce ventricular tachycardia by EPs[11]
Inpatient
- Emergent revascularization if ischemic
- Ablation
- Left sympathetic ganglionic blockade
- Deep sedation / general anesthesia
- IABP / ECMO
- Palliative care as this could represent impending terminal failure
Disposition
- Admit
See Also
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.
- ↑ Credner SC, Klingenheben T, Mauss O, et al. Electrical storm in patients with transvenous implantable cardioverter-defibrillators: incidence, management and prognostic implications. J Am Coll Cardiol 1998; 32:1909
- ↑ Hohnloser SH, Al-Khalidi HR, Pratt CM, et al. Electrical storm in patients with an implantable defibrillator: incidence, features, and preventive therapy: insights from a randomized trial. Eur Heart J 2006; 27:3027
- ↑ 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.