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!
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health, a Clinical Adjunct Associate Professor at Monash University, and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of LITFL.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of two amazing children.
On Twitter, he is @precordialthump.