Cardiac Electrical Storm

Aka: Cardiac Electrical Storm, Ventricular Electrical Storm, Ventricular Tachycardia Storm, Ventricular Fibrillation Storm

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II. Definitions

  1. Electrical Storm
    1. More than 3 episodes of serious ventricular Arrhythmia in 3 hours
      1. Sustained Ventricular Tachycardia
        1. Sustained VT lasts >30 sec or hemodynamic compromise
      2. Sustained Ventricular Fibrillation
      3. Appropriate Automatic Internal Cardiac Defibrillator (AICD) shocks

III. Epidemiology

  1. Incidence: 10-20% of those with AICD

IV. Risk Factors: Multiple appropriate shocks or electrical storm

  1. Structural heart disease
    1. Arrhythmogenic Right Ventricular Dysplasia (ARVD)
    2. Brugada Syndrome
    3. Cardiomyopathy (e.g. Hypertrophic Cardiomyopathy)
    4. Chagas Disease
    5. Automatic Internal Cardiac Defibrillator or AICD (electrical storm occurs in 40% of patients)
  2. Reversible Causes
    1. See Reversible Causes of Cardiopulmonary Arrest
    2. Antidysrhythmic medications
    3. Drug Toxicity
      1. Prolonged QT Interval due to Medication
      2. QRS Widening
    4. Increased sympathetic tone
    5. Acute on Chronic Renal Failure
    6. Acute on Chronic Congestive Heart Failure (CHF Exacerbation)
    7. Thyrotoxicosis
    8. Hypokalemia
    9. Hypomagnesemia

V. Labs

  1. See Reversible Causes of Cardiopulmonary Arrest
  2. Serum Electrolytes
  3. Serum Troponin
  4. Thyroid Stimulating Hormone

VI. Diagnostics

  1. Electrocardiogram
    1. QTc Prolongation
    2. QRS Widening
    3. Acute Coronary Syndrome (Myocardial Ischemia or Myocardial Infarction)

VII. Evaluation

  1. General
    1. Confirm Wide Complex Tachycardia (versus SVT with abberancy)
      1. Do not use Calcium Channel Blocker for wide complex unless absolutely certain of SVT
    2. Evaluate for secondary causes (e.g. infection, Electrolytes, Creatinine, Hemoglobin, Troponin, drug levels)
    3. Confirm multiple appropriate shocks from AICD
      1. Deactivate device with magnet if inappropriate shocks
  2. Unstable Patient presenting in ongoing ventricular Arrhythmia
    1. See Ventricular Tachycardia Management in the Adult
    2. See Ventricular Tachycardia Management in the Child
    3. See Unstable Tachycardia
    4. See Reversible Causes of Cardiopulmonary Arrest
  3. Stable patient
    1. Interrogate AICD
    2. See Labs and EKG above

VIII. Management: Unstable Patient with ongoing Electrical Storm

  1. See AICD Electrical Storm
  2. See Ventricular Tachycardia Management in the Adult
  3. See Ventricular Tachycardia Management in the Child
  4. Synchronized Cardioversion or Defibrillation
    1. First-line intervention
    2. Refractory to first shock
      1. Consider changing pad position
      2. Consider dual sequental Defibrillation
      3. Maximize delivered joules
  5. Avoid Epinephrine
    1. Increases sympathetic stimulation and may worsen electrical storm
  6. Specific Ventricular Tachycardias (if cardioversion or Defibrillation fails)
    1. Monomorphic Ventricular Tachycardia (regular Tachycardia with consistent QRS configuration)
      1. Typically due to old Myocardial Infarction scar
      2. Amiodarone
      3. Lidocaine
      4. Non-Selective Beta Blockers (e.g. Propranolol)
      5. Magnesium
      6. Radiofrequency ablation (if preserved EF, at least >25%)
    2. Polymorphic Ventricular Tachycardia
      1. Prolonged QTc (Torsades de Pointes)
        1. See Torsades de Pointes
        2. Magnesium Sulfate 2 grams or more loaded
        3. Isoproterenol
        4. Over-drive pacing
        5. Potassium Replacement if Hypokalemia
      2. Normal QTc
        1. Myocardial Ischemia
          1. Consider cath lab activation for coronary revascularization
        2. Brugada Syndrome
          1. Avoid Sodium Channel Blockers (e.g. Amiodarone, Procainamide, Lidocaine)
          2. Consider Isoproterenol
            1. If patient not currently in polymorphic Ventricular Tachycardia
          3. Quinidine (must be started before discontinuing Isoproterenol)

IX. Resources

  1. Electrical Storm (First10EM)
    1. https://first10em.com/electrical-storm/
  2. Non-torsade VT/VF storm (EM:Crit - Internet Book of Critical Care)
    1. https://emcrit.org/ibcc/storm/

X. References

  1. DeMeester and Mattu (2021) EM:Rap 21(8): 2-4
  2. Roukoz (2018) Cardiac Arrhythmia Conference, UMN, Minneapolis
  3. Eifling (2011) Tex Heart Inst J 38(2): 111-21 +PMID: 21494516 [PubMed]
    1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3066819/
  4. Sagone (2015) J Atr Fibrillation 8(4): 1150 +PMID: 27957218 [PubMed]
    1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5135177/

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