What is the management for a young female with stress cardiomyopathy, cardiogenic shock, and an ejection fraction (EF) of 30%, who experienced a pulseless ventricular tachycardia (VT) episode after a hanging incident?

Management of Stress Cardiomyopathy with Cardiogenic Shock and Pulseless VT After Hanging

The management of a young female with stress cardiomyopathy, cardiogenic shock, and EF 30% who experienced pulseless VT after hanging requires immediate mechanical circulatory support with VA-ECMO or other assist devices, along with targeted pharmacotherapy to stabilize hemodynamics and prevent recurrent arrhythmias. 1, 2

Initial Resuscitation and Stabilization

• Immediate defibrillation for pulseless VT is the definitive treatment with an initial shock of 200J, followed by 200-300J and then 360J if needed 1
• Establish advanced airway management and provide 8-10 breaths per minute with continuous chest compressions 1
• Administer epinephrine 0.01 mg/kg IV/IO every 3-5 minutes during cardiac arrest 1
• Correct electrolyte imbalances, particularly potassium and magnesium, which is recommended in patients with recurrent VT/VF 1
• Consider amiodarone 5 mg/kg IV bolus for refractory VT, which can be repeated up to 2 times 1, 3

Management of Cardiogenic Shock

• Mechanical circulatory support is the cornerstone of management for cardiogenic shock in stress cardiomyopathy with severely reduced EF 1, 2
• VA-ECMO is reasonable for persistent cardiogenic shock due to stress cardiomyopathy that is not responsive to maximal treatment measures 1, 4
• Alternative mechanical support options include intra-aortic balloon pump or percutaneous left ventricular assist devices 4, 5
• Vasopressors may be needed initially to maintain perfusion, with phenylephrine, norepinephrine, or vasopressin being options reported in literature 4
• Beta-blockers should be considered during the hospital stay and continued thereafter, but use with caution in acute shock 1

Management of Ventricular Arrhythmias

• Amiodarone should be administered at a loading dose of approximately 1000 mg over the first 24 hours, followed by a maintenance infusion of 0.5 mg/min (720 mg per 24 hours) 3
• 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 3
• Intravenous lidocaine may be considered for the treatment of recurrent sustained VT or VF not responding to beta-blockers or amiodarone 1
• Transvenous catheter overdrive stimulation should be considered if VT is frequently recurrent despite anti-arrhythmic drugs 1
• Radiofrequency catheter ablation followed by ICD implantation should be considered in patients with recurrent VT, VF, or electrical storms despite optimal medical treatment 1

Specific Considerations for Stress Cardiomyopathy

• Sedation is strongly recommended for agitation which can exacerbate catecholamine surge in stress cardiomyopathy 1
• Rapid external cooling is recommended for any hyperthermia that may develop 1
• Coronary angiography should be performed to exclude obstructive coronary disease, which is essential for confirming the diagnosis of stress cardiomyopathy 6
• Echocardiographic monitoring is crucial to assess for improvement in ventricular function, as stress cardiomyopathy typically resolves within days to weeks 6, 2

Long-term Management

• Complete recovery of systolic function can be expected with appropriate support through the acute phase 4, 2
• Oral treatment with beta-blockers should be continued after the acute phase 1
• Psychological assessment and treatment of distress are recommended, as emotional triggers can be associated with stress cardiomyopathy 1
• Regular follow-up echocardiography is needed to document recovery of left ventricular function 2

Potential Complications and Pitfalls

• Prolonged use of physical restraints without sedation is potentially harmful and should be avoided 1
• Prophylactic treatment with anti-arrhythmic drugs other than beta-blockers is not recommended 1
• Intravenous amiodarone at concentrations greater than 3 mg/mL in D5W has been associated with a high incidence of peripheral vein phlebitis; use concentrations of 2.5 mg/mL or less for peripheral administration 3
• Monitor for development of LV thrombi, which can be a complication of stress cardiomyopathy 6
• Be vigilant for recurrence of stress cardiomyopathy, which has been reported in approximately 12% of cases 6