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Paul R. - August 4, 2021 2:49 PM
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. - August 4, 2021 5:09 PM
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. - August 10, 2021 9:54 AM
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 - August 10, 2021 1:01 PM
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. - August 12, 2021 9:24 AM
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. - September 30, 2021 3:43 PM
Thank you both for Clarification. Keep up the good work.
Edward S. - January 6, 2022 10:15 AM
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?