HOW TO SURVIVE ELECTRICAL STORM

Transcription

1 HOW TO SURVIVE ELECTRICAL STORM DR. LAURA CHAHOUD, DO EMERGENCY MEDICINE PGY-4 ST MARY MERCY HOSPITAL OUTLINE What is electrical storm? Case intro ACLS Approaches to management Dual axis defibrillation Beta blockade Case summary Take home points 1

2 ELECTRICAL STORM Persistent VF or VT which does not resolve with standard ACLS protocol Varying definitions in the literature Gao et al. listed numerous definitions from the literature, citing sources which define electrical storm with varying durations of VF/VT, number of defibrillations, time between recurrent episodes of VT/VF, number of episodes of VF/VT (ranging from at least four to at least 20 ). Cabanas et al. performed a retrospective case series defining refractory VF as persistent VF following at least 5 unsuccessful single shocks, epinephrine administration and a dose of antiarrhythmic medication. Eiffling et al. defines ES as 3 or more sustained episodes of Vf/VT or appropriate ICD shocks within a 24 hr period. (Sustained VF/VT refers to at least 30 seconds, hemodynamic instability, or unresolved without intervention.) 2

3 CASE REPORT 67 yo male presents to the ED for evaluation of chest pain and has witnessed VF cardiac arrest. High quality CPR initiated and subsequent ACLS protocol without ROSC. ACLS PROTOCOL 3

4 Keys to successful resuscitation using ACLS protocol. 1. Early defibrillation 2. High quality CPR with minimal interruptions IMPROVING ACLS Utilization of End Tidal CO2 monitoring Ensures quality of CPR End tidal CO2 of >10 (ideally 12-15) indicates high quality CPR Arterial line placement Diastolic BP of <40, then give 1 mg epinephrine if within the 3-5 min as per ACLS Diastolic BP >40, do not administer dose of 1 mg epinephrine 4

5 EPINEPHRINE PITFALLS Beta stimulation in addition to the desired alpha stimulation. Increased myocardial oxygen demand due to increased chronotropy and inotropy. Decreased VF/VT threshold. Increased myocardial dysfunction. WHEN ACLS FAILS, WHAT NEXT? Two approaches to consider Dual axis defibrillation Sympathetic blockade 5

6 DUAL AXIS DEFIBRILLATION DUAL AXIS DEFIBRILLATION There are theories why VF/VT sometimes doesn t respond to single defibrillator shock. 1. vector of energy across myocardium (i.e. pad placement) 2. energy required to defibrillate 95% of the myocardium (i.e. habitus) Ultimately the goal of dual axis defibrillation is to reset the electrical activity of the myocardium. 6

7 DUAL AXIS DEFIBRILLATION Hoch described double sequential external shocks as a successful intervention for refractory v-fib as early as These five cases, all performed in the electrophysiology suite, had standard single axis defibrillator shocks administered over twenty times without success, but were converted back to a normal sinus rhythm after dual-axis defibrillation. In 2013, Leacock described the first case of successful RVF conversion in the ED after failure of ACLS protocols with two dual-axis defibrillation shocks. In 2015, Cabañas reported on ten cases of refractory VF treated with double sequential external defibrillation in the prehospital setting. Three of these patients had return of spontaneous circulation (ROSC), but none survived to discharge with their protocols. 7

8 SYMPATHETIC BLOCKADE SYMPATHETIC BLOCKADE Beta blocker use has been studied since the 1960s in cardiac arrest, and is known to decrease VF and sudden cardiac death after MI. Nademanee et al. compared sympathetic blockade in ES with beta blocker or left stellate ganglion blockade (LSGB) to standard ACLS guidelines Driver et al. wrote a retrospective observational analysis of 25 patients in RVF Compared patients who received esmolol to those who did not Required at least 3 defibrillation attempts, 300 mg amiodarone, and 3 mg epinephrine for inclusion 8

9 SYMPATHETIC BLOCKADE Nademanee et al. found increased survival rates at 1 week (21 of 27 treated with sympathetic blockade and 4 of 22 treated with standard ACLS protocol) and 1 year. Driver et al. found 6 of 25 received esmolol and all 6 achieved at least temporary ROSC 4 of 6 had sustained ROSC with 3 surviving to hospital DC with good neurologic outcome Compared to 19 of 25 did not receive esmolol, 6 sustained ROSC and 2 surviving to DC with good neurologic outcome Nademanee et. al; Treating Electrical Storm Sympathetic blockade versus advanced cardiac life support-guided therapy 9

10 CASE SUMMARY Patient found to be in refractory VF/electrical storm. Second set of defibrillation pads applied in AP fashion with dual simultaneous shock administered of 300J from each device. No change from VF; CPR continued. 80 mg esmolol administered and allowed to circulate with a round of CPR; esmolol drip at 0.1 mg/kg/min. Second dual axis shock administered with ROSC and pulse ox 90%. Intubation attempted and patient yelled, Stop that! 10

11 CASE REVIEW Post ROSC EKG showed STEMI and patient was taken to cardiac cath. LAD stented and ultimately patient discharged home neuro intact 3 days later. This case is quite unique in that it describes the first successful use of dual-axis defibrillation and esmolol administration with the patient surviving to outpatient follow up. TAKE HOME POINTS Refractory VF/VT Consider Electrical storm and think outside of the box. Dual Axis Defibrillation Reset the electrical activity of the heart through multiple vectors and higher energy. Suppress adrenergic response with Beta Blockade Decrease VF/VT threshold Decrease myocardial O2 demand 11

12 THINGS TO CONSIDER Although there have been no doubled-blinded randomized control studies supporting use of dual axis defibrillation and beta blockade, literature available shows benefit to patient outcomes using dual axis defibrillation and beta blockade. Consider use of dual axis defibrillation in conjunction with beta blockade as a last stitch effort for patients in electrical storm. REFERENCES Gao D1, Sapp JL. Electrical storm: definitions, clinical importance, and treatment. Curr OpinCardiol. 2013;28(1):72-9. Cabañas JG, Myers JB, Williams JG, et al. Double sequential external defibrillation in out-of-hospital refractory ventricular fibrillation: a report of ten cases. Prehosp Emerg Care. 2015;19(1): Eifling M, Razavi M, Massumi A. The evaluation and management of electrical storm. Tex Heart Inst J. 2011;32(8):

13 REFERENCES Hoch DH, Batsford WP, Greenberg SM, et al. Double sequential external shocks for refractory ventricular fibrillation. J Am Coll Cardiol. 1994;23(5): doi: / (94) Leacock BW. Double simultaneous defibrillators for refractory ventricular frillation. J Emerg Med. 2014;46(4): doi: /j.jemermed Nademanee K, Taylor R, Bailey WE, et al. Treating electrical storm: sympathetic blockade versus advanced cardiac life support-guided therapy. Circulation. 2000: 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): doi: /j.resuscitation REFERENCES Rezaie, Salim. Beyond ACLS: Dual Simultaneous External Defibrillation. REBEL EM. 16 July Web. 31 May Shariff, Sameer. My Heart Goes Boom ß-Blockers in Cardiac Arrest. CanadiEM. 15 August Web. 06 June Rezaie, Salim, host. Rational Evidence Based Evaluation of Literature in Emergency Medicine Cast (REBEL EM Cast). Available at itunes.com and Google Play. Published on July 6, Scott Weingart. Podcast 191 Cardiac Arrest Update. EMCrit Blog. Published on January 23, Accessed on June 3, Available at [ 13