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:

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.

Episode 190: Electrical Storm