Cardiology Corner: Electrical Storm

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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN
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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., M.D. -

Paul,
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.

Amal

Joshua A., D.O. -

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!

Susanne 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., M.D. -

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., D.O. -

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

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