HPI:
- A 58 year old male with a past medical history of CAD s/p PCI, cardiomyopathy with EF 30-35% c/b VF arrest s/p ICD presents via EMS as a STEMI alert.
- While en route, patient had episode of VT on the cardiac monitor and was defibrillated by the ICD almost immediately, returning to narrow complex rhythm.
- He remains neurologically intact and states that 1 hour ago he started having crushing substernal chest pain and feels like he is going to die.
Physical Exam:
Vitals: BP 84/40, HR 39, RR 20, SpO2 94%
- GCS 15, moves all extremities equally
- Appears pale, diaphoretic, in obvious extremis
- Bradycardic with cool extremities
- Trace pitting edema in bilateral lower extremities
EKG interpretation: Junctional rhythm with PVCs in pattern of bigeminy. Inferior STEMI with reciprocal ST segment depressions in lateral leads.
Case continued:
- Patient was given 324mg aspirin en route by EMS. Additionally given 300 mg amiodarone bolus, 4000 U heparin bolus, and 500 cc LR bolus upon arrival to ED.
- During initial resuscitation, cardiac rhythm converts to VT and patient is immediately defibrillated by ICD with ROSC and remains neurologically intact.
- Patient persistently hypotensive and norepinephrine infusion is initiated to MAP > 65.
- Patient experiences another episode of VT and is again immediately defibrillated by ICD with ROSC and remains neurologically intact.
- Decision is made in junction with cardiology and interventional cardiology to transport patient immediately to catheterization lab. During the procedure, the patient continues to have multiple episodes of VT and VFib and undergoes general anesthesia and is intubated. The angiogram demonstrates a 100% occlusion of the proximal RCA. The patient recovers in the CCU and was discharged on hospital day 5.
Pearls:
- Electrical storm is defined by 3 or more sustained episodes of VT, VFib, or appropriate shocks from an ICD within 24 hours.
- Initial management adheres to ACLS protocol with strict attention to airway, breathing, and circulation.
- Medications include epinephrine, amiodarone, and lidocaine
- Consider the following for refractory VT/VF (electrical storm):
- Esmolol or other beta blockade agents
- Dual sequential defibrillation
- Ultrasound guided stellate ganglion block
- VA-ECMO
References:
Eifling M, Razavi M, Massumi A. The evaluation and management of electrical storm. Tex Heart Inst J. 2011;38(2):111-121.
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;85(10):1337-1341. doi:10.1016/j.resuscitation.2014.06.032
