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FACP. Colegio de médicos de Tarragona Nº 4305520 / fgcapriles@gmail.com




Tuesday, May 24, 2016

Electrical Storm

Resultado de imagen de AAEM/Rsa
- AAEM/RSA - May 22, 2016 - By Khalid M Miri
"Cardiac electrical storm (ES) is often defined as three or more episodes of sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) within 24 hours. It is a dangerous arrhythmia that leads to refractory VF and will kill most of its victims despite treatment with the current ACLS recommendations of epinephrine, antidysrhythmics, CPR, and defibrillation...
With evidence suggesting potentially significant benefits to using beta blockers in refractory VF, Drs. McGovern and McNamee have suggested a new treatment algorithm for these grim cases. When faced with continued VF arrest after at least 3mg of epinephrine, 300mg of amiodarone (or one dose of another antidysrhythmic), and 3 attempts of defibrillation, use the following algorithm:
  • Add a second set of defibrillation pads in the opposite location of the first set. If the patient has pads anterior-posterior, add anterior-apex pads and vice versa (research shows double sequential external defibrillation in refractory VF significantly increases chances to terminate the VF and achieve ROSC vs single pads.)
  • Continue high quality CPR and consider withholding further doses of epinephrine. 
  • Rhythm check. If VF then defibrillate at 360 J from both sets of pads simultaneously from two separate devices. 
  • Bolus esmolol at 0.5 mg/kg and initiate a continuous infusion of esmolol at 0.1mg/kg/hr while CPR continues. 
  • Rhythm check. If VF then defibrillate again at 360 J from both sets of pads simultaneously from two separate devices. 
  • Continue esmolol infusion along with high-quality CPR and correct electrolytes, if not previously corrected. 
  • Terminate CPR if ROSC is achieved or patient is deemed unsalvageable by treating physician.
Cases of refractory VF are often hopeless, but this research shows there might be a new way to treat these patients. Randomized controlled trials using beta-blockers for refractory VF are the next step, but until then it is worth discussing this research and new algorithm with our attendings and deciding whether your team wants to try this new approach before giving up on your next refractory VF arrest. You may save more lives than you thought possible."