Electrical Storm

Reviewed and revised 14 September 2014

OVERVIEW

• aka refractory VF/ VT
• aka arrhythmic storm
• can be extremely difficult to manage!

DEFINITION

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

PATHOPHYSIOLOGY

• 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

MANAGEMENT

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
• Drugs:
  • Amiodarone
  • Magnesium
  • Lignocaine

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:

• ECMO

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

Journal articles

• 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!