What is the treatment for a patient experiencing ventricular tachycardia (V tach) storm?

Treatment for Ventricular Tachycardia Storm

For patients experiencing ventricular tachycardia storm, immediate treatment with intravenous amiodarone (150 mg over 10 minutes followed by infusion of 1.0 mg/min for 6 hours, then maintenance at 0.5 mg/min) combined with beta-blockers is the most effective approach. 1, 2

Initial Assessment and Management

• First determine if the patient is hemodynamically stable or unstable by checking for adverse signs such as hypotension, chest pain, heart failure, or high heart rate 2, 3
• For unstable VT with pulse, perform immediate synchronized DC cardioversion (100J, 200J, 360J) with sedation if the patient is conscious 3
• For hemodynamically stable VT, proceed with pharmacological management 1

Pharmacological Management for VT Storm

First-Line Therapy

• Intravenous beta-blockers are the single most effective therapy for polymorphic VT storm 1
• Intravenous amiodarone is recommended at 150 mg infused over 10 minutes, followed by a constant infusion of 1.0 mg/min for 6 hours and then maintenance at 0.5 mg/min 1, 2
• For FDA-approved dosing, amiodarone can be given as 1000 mg over the first 24 hours (loading dose), followed by maintenance infusion of 0.5 mg/min (720 mg/24 hours) 4

Alternative Agents

• Lidocaine can be used as an alternative: 1.0-1.5 mg/kg bolus, with supplemental boluses of 0.5-0.75 mg/kg every 5-10 minutes to a maximum of 3 mg/kg total loading dose, followed by infusion of 2-4 mg/min 1
• Procainamide is another option: 20-30 mg/min loading infusion up to 12-17 mg/kg, followed by infusion of 1-4 mg/min 1

Special Considerations

• For torsades de pointes, magnesium (8 mmol) is recommended if hypomagnesemia is suspected 1, 3
• Reduce infusion rates of lidocaine in older patients and those with CHF or hepatic dysfunction to avoid toxicity 1
• Reduce procainamide infusion rates in patients with renal dysfunction 1

Advanced Management Strategies for Refractory VT Storm

• For breakthrough episodes of VF or hemodynamically unstable VT, use 150 mg supplemental infusions of amiodarone mixed in 100 mL of D5W and infused over 10 minutes 4
• Overdrive pacing may be considered for patients with frequently recurring or incessant VT 1
• General anesthesia may be considered for patients with frequently recurring or incessant VT 1
• Spinal cord modulation may be considered for some patients with frequently recurring or incessant VT 1
• Double sequential cardioversion can be effective for VT refractory to standard cardioversion 5

Addressing Underlying Causes

• Aggressive treatment of heart failure is essential in patients with LV dysfunction due to prior MI and ventricular tachyarrhythmias 1
• Aggressive treatment of myocardial ischemia is crucial in patients with ventricular tachyarrhythmias 1
• Coronary revascularization is indicated when there is clear evidence of acute myocardial ischemia preceding VF 1

Important Precautions

• Administer amiodarone through a central venous catheter whenever possible, especially for concentrations greater than 2 mg/mL 4
• Use an in-line filter during administration of amiodarone 4
• Monitor for hypotension, which is more common with daily doses above 2100 mg 4
• Do not exceed an initial amiodarone infusion rate of 30 mg/min to avoid hepatocellular necrosis and acute renal failure 4
• For infusions longer than 1 hour, do not exceed amiodarone concentrations of 2 mg/mL unless a central venous catheter is used 4
• Amiodarone is more effective than lidocaine for shock-resistant VT (78% vs 27% immediate termination rate) 6