Emergency medicine podcasts, reviews and curbside consults
ERCAST 020
What do you do when you get to the end of the ventricular tachycardia algorithm your patient is still in Ventricular tachycardia (VT or V-Tach).
You are now off the map of ACLS and in the middle of a V-Tach Storm.
We go step by step through a case of incessant ventricular tachycardia with pearls, pitfalls and things to think about when the fecus is hitting the fan.
About Rob OrmanDeceptively tall.
Podcaster to the stars, father of many, lover of few
[...] an excellent article courtesy of Dr. RW.Recommended by Scott Weingart Learn more: ERCAST — V Tach Storm; Dr RW — Managing patient with electrical storm Mebazaa A, Gheorghiade M, Piña IL, [...]
[...] -- By the way, you might appreciate Rob Orman’s podcast ERCAST, where he talks about treating refractory VT. (http://blog.ercast.org/2010/12/v-tach-storm/) [...]
[...] Dr. Orman’s podcast -- V Tach Storm -- hemodynamically unstable is where the patient ended up after amiodarone. The [...]
Hi Rob. Thanks for the podcast. I am a junior trainee (so please forgive any naïveté) but from your case, I am assuming that these tips relate to VT with pulse only, not the pulseless VT arm of the ACLS pathway. Is there any role for some of these tips in pulseless VT (understanding the ongoing discussion on the actual benefit of drugs in ACLS)?
Thanks
Ryan
NICE case of “VT Storm” (Sorry, I’m just getting to this now = 2012 -- but you recorded it back in Dec, 2010 … ). KEY message (as you emphasize) is NOT to forget about Beta-Blockers in the “algorithm” of refractory VT. Nice on-line reference (at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3066819/ ) supporting my longtime impression that although Beta-Blockers aren’t routinely used (and probably not needed) in many cases of sustained VT -- on occasion, they may be the ONLY medication to work. A BIG clue that this was needed in the case you present is that your patient briefly came OUT of sustained VT, at which time (in addition to PVCs), there was sinus tachycardia -- which should be a clue to underlying increased sympathetic activity -- which is a major mechanism by which beta-blockers may work.
You discussed Procainamide (as well as the Lidocaine and Amio that were given) -- and I completely agree with your valid concerns about potentially aggravating the already low BP. One important point to make is that for sustained VT -- Lidocaine is now viewed as 3rd-line (at best) behind Amio, Procainamide -- and perhaps Sotalol (though much less experience with the latter in this country in IV form).
Again -- EXCELLENT informative case!