Cardiology Corner: Electrical Storm

Sign in or subscribe to listen

No me gusta!

The flash player was unable to start. If you have a flash blocker then try unblocking the flash content - it should be visible below.

Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN

No me gusta!

The flash player was unable to start. If you have a flash blocker then try unblocking the flash content - it should be visible below.

Paul R. -

2 questions:

In terms of electrical storm from monomorphic V-tach, what is the consensus on Esmolol ?
In terms of NA+ channelopathies, does Amps of NA+ HC03- have a role in conjunction with Isoproterenol?

Amal M. -

Esmolol is perfectly fine. If you are comfortable with that and have quick access, go with that?
In terms of sodium channelopathies, are you referring to things like antiarrhythmics? If so, if you are worried about toxicity, then I would definitely give bicarb.


Joshua A. -

A bit confused on when to reach for Beta Blockers (monomorphic seems best) vs Overdrive pacing/isoproterenol/epi (Brugada seems best) or polymorphic of unclear etiology? Safe to say not to use epi, isoproterenol in monomorphic and potential use in polymorphic due to effects of increase heart rate on lowering Qtc? Thanks, and great talk as usual!

Susy D, MD -

Thanks for listening!

1. For refractory monomorphic VT/VF--> beta-blockers, amio, lidocaine, propofol, stellate ganglion block :)
2. For prolonged QT/TdP/PVT--> replete Mg and K
3. Brugada or short QT--> isoproterenol

Does that help simplify?

Amal M. -

I would add:
for torsades (i.e. prolonged QT PVT), you'd want to shock first; if that does work, start Mg drip and look for & tx underlying cause

if the shocks don't work OR if it is intermittent (so you really don't have a chance to shock), go with Mg and try to increase the HR using overdrive electrical pacing (you can use a goal HR of ~ 120) or overdrive chemical pacing with EPI or DA drip, and then look for & tx underlying rhythm

for long QT PVT, remember that the QTc wlll relatively lengthen with slow HRs, so keep HR fast, stay away from BBs, and be wary that these patients are more likely to have their PVT set off by slow HRs, e.g. if they take opiates

the one exception to the above: there are some types of congenital long-QT conditions which DO respond better to beta blockers and worsen with fast HRs, but I'll bet that those patients are pretty much always diagnosed in childhood

for normal QT-PVT, also remember that the MOST common cause is ischemia, so initiate anti-ischemic therapy and try to get to cath

for monomorphic VT with a pulse, I would stay away from sympathomimetic drugs e.g. EPI/DA, etc.

Joshua A. -

Thank you both for Clarification. Keep up the good work.

Edward S. -

Sorry for asking this question late, but I was reviewing this (spaced repetition and all that...) and had a case a few months ago with a young man with structural heart disease with an AICD who went into refractory VFib while in the ED. He came in with vague complaint of not feeling well, and may have been intoxicated.

I wound up shocking him 3 times - after his AICD shocked him 5 times - while loading him with Amiodarone which worked to control the dysrhythmia. I called our Cardiologist on-call and she said that if he went back into Vfib, to use Propofol. At first I think she was jokingly suggesting that I intubate and sedate the patient, but then I did some research and found the following:

Burjorjee JE, Milne B. Propofol for electrical storm; a case report of cardioversion and suppression of ventricular tachycardia by propofol. Can J Anaesth. 2002 Nov;49(9):973-7. doi: 10.1007/BF03016886. PMID: 12419728.

There were a few other case reports of Propofol successfully converting ventricular dysrhythmias, possibly due to anti-sympathetic properties. Are there any more structured guidelines on the use of Propofol in these cases?

Thank you

To join the conversation, you need to subscribe.

Sign up today for full access to all episodes and to join the conversation.

To download files, you need to subscribe.

Sign up today for full access to all episodes.
EM:RAP 2021 August Full episode audio for MD edition 216:47 min - 229 MB - M4AEM:RAP 2021 August German Edition Deutsche 109:56 min - 151 MB - MP3EM:RAP 2021 August PA Edition PA Edition 81:24 min - 112 MB - MP3EM:RAP 2021 August French Edition Français 27:06 min - 37 MB - MP3EM:RAP 2021 August Spanish Edition Español 47:57 min - 66 MB - MP3EM:RAP 2021 August Farsi Edition Farsi 179:31 min - 247 MB - MP3EM:RAP 2021 August Aussie Edition Australian 0:49 min - 1 MB - MP3EM:RAP 2021 August Canadian Edition Canadian 0:27 min - 736 KB - MP3EM:RAP 2021 August Board Review Answers 156 KB - PDFEM:RAP 2021 August Board Review Questions 500 KB - PDFEM:RAP 2021 August MP3 Files 248 MB - ZIPEM:RAP 2021 August Spanish Written Summary 403 KB - PDFEM:RAP 2021 August Written Summary 664 KB - PDF