Electrical storm

Revision as of 13:52, 22 March 2016 by Ostermayer (talk | contribs) (Text replacement - "Category:Cards" to "Category:Cardiology")

Background

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)

^Fixed or rate-related

ICD malfunction

  • AF/SVT
  • Oversensing
  • Lead fracture

Diagnosis

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
      • 67% vs. 5% survival in 49 pt study, respectively for esmolol/propranolol vs. ACLS antiarrhythmic[4]
      • Pts who survived initial ES event did well over 1 yr follow up
    • Metoprolol 2.5-5 mg IV q2-5 min to max of 15 mg
    • Propranolol 0.15 mg/kg IV over 10 minutes followed by 3-5 mg q6h; may be effective even if metoprolol fails
    • Esmolol 300-500 mcg/kg load over 1 minutes follwed by infusion at 25-50 mcg/kg/min initial dose
  • 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 @ 90-120 or start Isoproterenol infusion @ 2 mcg/min and titrate to HR 90-100
    • Brugada

Inpatient

  • Emergent revascularization if ischemic
  • Ablation
  • Left sympathetic ganglionic blockade
  • Deep sedation / general anesthesia
  • IABP / ECMO

Disposition

  • CCU or cath lab

See Also

External Links

References

  1. 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.
  2. 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.
  3. Eifling M, Ravazi M, Massumi A. The Evaluation and Management of Electrical Storm. Tex Heart Inst J 2011;38(2):111-21
  4. Nademanee K et al. Treating Electrical Storm: Sympathetic Blockade Versus Advanced Cardiac Life Support–Guided Therapy. Circulation. 2000; 102: 742-747.