Advanced Practice - Got a rhythm and it won't let go....

Electrical storm

  • Recurrent or refractory ventricular dysrhythmia (VT or VF), variably defined as multiple episodes within a certain period of time
  • Usually due to severe cardiomyopathy, rarely caused by electrolyte disturbances, medications, thyroid storm, or acute MI


Treatment pathway

1. Amiodarone: You're probably doing this anyway as it is AHA/ACC recommended in ACLS guidelines. Remember you can rebolus multiple times: 150 mg over 10 minutes.

2. Beta blockade: Thought to suppress the exaggerated sympathetic outflow which may contribute to electrical storm. Consider propranolol at 0.5 mg bolus and 0.2 mg/min as nonselective beta blockade may be more efficacious than only B1 blockade (i.e. with metoprolol).

3. Propofol: If you are sedating a patient for cardioversion and their BP can handle it, use propofol as it has been shown in multiple case reports to possibly terminate electrical storm due to its central vagotonic effects and suppression of sympathetic outflow.

4. Call electrophysiology: Catheter ablation is highly effective in terminating electrical storm if the patient fails the above measures.