Electrical storm - Refractory VT & VF

Question 1

What is defined as 3 or more sustained episodes of ventricular tachycardia (VT), ventricular fibrillation (VF), or appropriate implantable cardioverter-defibrillator (ICD) shocks during a 24-hour period?

Answer 1

Electrical storm

Question 2

What role does sympathetic drive play in electrical storm cases?

Answer 2

Sympathetic surge leading to increased mycocyte sensitivity which is exacerbated by regular DCR and adrenaline

Question 3

What is the electrical storm mantra regarding medications?

Answer 3

“beta-blockers good, adrenaline bad!”

Question 4

Fill in the blank: VF storm in the setting of _______ may respond to isoprenaline.

Answer 4

Brugada syndrome

Question 5

What is high-energy defibrillation using simultaneous shocks also known as?

Answer 5

Double down defibrillation
X2 sets of pads AP and sternal synchronised

Question 6

How should defibrillator pads be applied for double down defibrillation?

Answer 6

Two sets: one in traditional sternum/apex configuration and the other in AP configuration

Question 7

What should be done if VT/VF persists despite ~5 shocks?

Answer 7

Coordinate the simultaneous firing of both defibrillators

Question 8

Name three drugs used in VT storm

Answer 8

• Amiodarone 300mg
• Magnesium 2-4 grams
• Lignocaine 1-5mg/kg

Question 9

What medication should be considered to attenuate sympathetic drive?

Answer 9

Esmolol starting 50mcg/kg/min

Question 10

What should be avoided when attenuating sympathetic drive?

Answer 10

Adrenaline

Question 11

What technique can be used for sympathetic blockade?

Answer 11

Ultrasound-guided stellate ganglion blockade

Question 12

In the context of Brugada syndrome, what infusion should be considered during an electrical storm?

Answer 12

Isoprenaline infusion 0.5-4mcg/min

Question 13

Name one medication that seems paradoxical in treating electrical storm in Brugada syndrome.

Answer 13

Isoprenaline

Question 14

Which drug is typically not effective for VF storm in Brugada Syndrome?

Answer 14

Other anti-arrhythmics such as beta blockers, amiodarone, lignocaine and magnesium

Question 15

Fill in the blank: For electrical storm in Brugada syndrome, consider _______.

Answer 15

Quinidine

Question 16

How is refractory VF different to refractory VT and Torsades de Pointes?

Answer 16

Refractory VF will no longer respond to normal ALS therapies.

Approach to refractory VF:
1. Amiodarone 300mg IV
2. Double pad defibrillation: 1 AP, 1 sternal
3. Esmolol 500mcg/kg (normal dose is 50mcg/kg/min)
4. Stellate ganglion block (better in refrac VT)

Magnesium 6grams IV is a good treatment for Torsades De Pointes but not once its degraded into VF (you can give it but it doesn’t improve ROSC or survival)

Evidence that esmolol increases ROSC and neurologically intact
Ongoing doses of adrenaline causes activation of the ryanodine receptor which causes myocardial cell calcium influx which can lead to electrical instability