Reviewed and revised 14 September 2014
- aka refractory VF/ VT
- aka arrhythmic storm
- can be extremely difficult to manage!
- 3 or more sustained episodes of ventricular tachycardia (VT), ventricular fibrillation (VF), or appropriate implantable cardioverter-defibrillator (ICD) shocks during a 24-hour period
- sympathetic drive plays a role in many cases
- hence the electrical storm mantra: “beta-blockers good, adrenaline bad!”
- however, electrical storm may result from different underlying pathologies, e.g. VF storm in the setting of Brugada syndrome or early repolarisation may respond to isoprenaline
Perform usual resuscitation measures first
- attend to ABCs
- adhere to ILCOR guidelines
- seek and treat underlying causes and complications
Continue effective CPR
- consider using devices such as LUCAS CPR and ResQPod impedance threshold device (the effectiveness of prolonged CPR dwindles as rescuers fatigue)
Consider these options for refractory VT/VF:
- High-energy defibrillation using simultaneous shocks (aka “double down” defibrillation)
- Apply 2 sets of defibrillator pads to the patient; one in traditional sternum/apex configuration and the other in AP configuration
- If VT/VF persists despite ~5 shocks, coordinate the simultaneous firing of both defibrillators
Consider attenuating the sympathetic drive:
- Esmolol (or other beta-blockers)
- avoid adrenaline
- Ultrasound-guided stellate ganglion blockade
Electrical storm in Brugada syndrome:
- consider isoprenaline infusion (seems paradoxical given the above advice regarding esmolol, but seems to work!) (also used successfully for VF storm in the context of early repolarisation)
- consider quinidine
- other anti-arrhythmics such as beta blockers, amiodarone, lignocaine and magnesium are not usually effective for VF storm in Brugada Syndrome
Consider extracorporeal support:
Consider radiofrequency catheter ablation:
- if electrophysiological studies have localised a region giving rise to VF-inducing PVCs
Patients with VT/VF storm should usually go to the cath lab post-ROSC
References and Links
- Driver BE, Debaty G, Plummer DW, Smith SW. Use of esmolol after failure of standard cardiopulmonary resuscitation to treat patients with refractory ventricular fibrillation. Resuscitation. 2014 Jul 14. PMID: 25033747.
- Eifling M, Razavi M, Massumi A. The evaluation and management of electrical storm. Tex Heart Inst J 2011;38(2):111–121. PMC3066819
- Gao D, Sapp JL. Electrical storm: definitions, clinical importance, and treatment. Curr Opin Cardiol. 2013 Jan;28(1):72-9. PMID: 23160339.
- Maury P, Hocini M, Haïssaguerre M. Electrical storms in Brugada syndrome: review of pharmacologic and ablative therapeutic options. Indian Pacing Electrophysiol J. 2005 Jan 1;5(1):25-34. PMC1502067
FOAM and web resources
- Dr Smith’s ECG Blog — 68 minutes with chest compressions, full recovery. Plus recommendations from a 5-member panel on cardiac arrest.
- Resus Review — High Energy Defibrillation for Incessant Ventricular Fibrillation
- Resus Review — Ultrasound Guided Stellate Ganglion Block for Refractory Ventricular Fibrillation
- UMEM Pearls — Non-stop VFib? Double down on the defib!