Electrical Storm

Electrical Storm

Background

• three or more episodes of sustained ventricular tachycardia, ventricular fibrillation, or appropriate ICD shocks in a 24 hour period

• frequently, hemodynamic unstable

• believed to mostly be due to catecholamine surge (sympathetic overdrive), but need to consider the causes below:

  • MI

  • Electrolytes

  • Acute HF

  • QT prolongation/shortening

  • Torsades

  • Brugada

  • Thyroid storm

  • Drugs

  • Sepsis

• Presentation is broad

  • May complain of pain from ICD shocks, palpitations, syncope

  • Can present in cardiac arrest

Management

• ABCs

• ACLS guidelines should be followed

  • Pulse (VT)==>cardiovert

  • Pulseless (VT/VF)==>defibrillate

    1. Consider dual defibrillation if VT/VF persists after 5 delivered shocks (see image below)

       1. Coordinate firing of both defibrillators at the same time
          

• Should you place a magnet over ICD if patient has one?

  • Remember, magnets turn of the ability to defibrillate, but don't affect pacing capability

  • If you want the patient to be shocked then do not place a magnet, unless you think you’re dealing with something other than VF/VT and thus it is shocking inappropriately (sinus tach, afib)

    1. Practice variation exists. Some will place the magnet, especially if the pt is stable, to spare pt more anxiety/pain contributing to the storm

• Start them on an anti-arrhythmic

  • Amiodarone 300mgè150mg IV //

  • Procainamide 10 mg/kg IV over 20 min //

  • Lidocane 1-1.5mg/kg IV

• Add a Beta Blocker to suppress the sympathetic tone and increase the dysrhythmia threshold

  • Metoprolol 2.5-5mg IV q2-5min //

  • Propranolol .15mg/kg IV over 10 min followed by standing order//

  • Esmolol 300-500 mcg/kg push followed by drip

• Consider an anxiolytic or sedation

• Brugada

  • Unlike aforementioned, VF in these pts is thought to be due to excessive vagal tone

    1. Isoproterenol drip will increase the sympathetic tone

  • Quinidine has been shown to help

• Torsades

  • Magnesium, replete electrolytes

  • If have episodes of bradycardia then add isoproterenol drip

Dispo

• Admit to CCU if possible

• May need cath lab, ablation, ECMO

LITFL

First10EM

Unstable Bradycardia

Unstable Bradycardia

Background

·       HR less than 60 BPM

·       Not all bradycardia is bad and scary, some presentations are benign and asymptomatic

·       Broad differential, some examples include:

• Cardiac (structural/EP): AV block, STEMI, CHD, CM, Aortic dissection, etc.

• Respiratory: Hypoxia, resp failure

• Infectious: Myocarditis (viral), Lymes dx, etc.

• Metabolic/Endocrine: electrolytes, hypothyroidism/myxedema coma, hypoglycemia, hypothermia, heat exhaustion/stroke

• Tox/iatrogenic: BB, CCB, Dig, Clonidine, Opioids, TCAs, Keppra, Amio, etc.

• Trauma: increased ICP, spinal injury

·       Place pacer/Zoll pads on patient

·       ACLS guidelines for bradycardia exist

Unstable patient

·       ABCs

·       Don’t let the patient D.I.E

• Think drugs, ischemia, electrolytes

·       Place on monitor and obtain access

• If cant get an pIV, then try IO or central line

• *send for labs, VBG/BMP asap. Looking for electrolyte derangements (hyperK) that can change management

·       Place transcutaneous pacer pads so you’re ready to pace at any moment

• Anterior/posterior position best

·       Try atropine

• Doesn’t hurt to try, may work

• .5mg IV, can be repeated q3min to a max dose of 3mg

·  If atropine is not working, high probability it wont, then start transcutaneous pacing while getting chronotropic medication (pressors) ready and then titrating to desired effect

• Place dial on pacer mode

• Set pacer rate >30BPM above pts intrisic rhythm (usually 60-80 BPM)

• Set mAmp on 40, increase by 5mAmp as needed

• Monitor for capture

  • Electric capture: downward pacer spike followed by wide QRS

  • Mechanical capture: palpate pulse and correlate with monitor/pulse ox

• Try to give pt something for pain

• Get ready to place a TVP

·       Pressors

• “For symptomatic bradycardia or unstable bradycardia IV infusion a chronotropic agent (dopamine & epinephrine) is now recommended as an equally effective alternative to external pacing when atropine is ineffective.”

  • Thought: takes time to draw up meds/titrate. start external pacing. Get meds ready and administer, especially if hypotensive.

• Can start either Epinephrine 2-20 micrograms/min or Dopamine 2-20 micrograms/kg/min, titrate accordingly

  • If epi/dopamine don’t work separately, then try them together

    • If bradycardia still not improving, then try isoproterenol 2-10mcg/min

      • Isoproterenol is an analog of epinephrine

·       Additional medications to consider

• Digoxin  

  • Send dig level

  • Consider digibind

• CCB

  • Calcium gluconate, high dose insulin

• BB

  • Glucagon, high dose insuli

• Organophosphates

  • Atropine, pralidxime

·       STEMI?

• Usually inferior wall MI

• Advocate for pt to go to cath lab

Penetrating Neck Injury

Penetrating Neck Injuries 

Background

·       1% of all trauma admissions

·       5% mortality rate

• vascular injuries most common cause

  • 20% mortality secondary to uncontrolled hemorrhage

• missed esophageal injury = highest cause of delayed death in this population

·     up to 20% have tracheobronchial injuries

·       Many important structures in the neck

• Divided into different levels or “ZONES”

·       Zone I: clavicles/angle of sternum to cricoid cartilage

o    Contains proximal portion of common carotid artery,  subclavian artery, vertebral artery, lung apices, trachea, thyroid, esophagus, thoracic duct, spinal cord

·       Zone II: Cricoid cartilage to angle of the mandible

o    Contains carotid artery, vertebral artery, jugular veins, pharynx, trachea, esophagus, larynx, vagus nerve, recurrent laryngeal nerve, spinal cord

o    Traditionally, went to OR for exploration (see below)

·       Zone III: angle of mandible to base of skull

o    Vertebral artery, distal carotid artery, salivary and parotid glands, spinal cord, CN 9 through 12, spinal cord

·       *penetrating injuries can involve more than one zone

·       * platysma muscle sits between superficial and deep cervical fascia (see below)

• mostly in Zone II (and part of III)

• penetration of platysma increases chance of serious injury

  • previously, all of these patients went to OR. now, can obtain CTA neck if stable and don’t meet hard signs (see below)

Management

o    A.B.Cs, A.B.Cs, and some more A.B.Cs (+D.E.F…never forget full exposure in your penetrating trauma, in between groin, under axilla, etc.)

•   Monitor for exsanguination and asphyxiation

o    Violation of the platysmaàCTA neck (stable) vs. OR (unstable or hard signs)

o    Hard and soft signs to further classify severity of injury (chart below)

• 90% rate of major injury with hard signs!

  •   If ANY of the hard signs or hemodynamic instability are present—> OR

    • no pit stop to the CT scanner

    •  only to be delayed to secure unstable airway or tamponade bleeding

• If only soft signs (+stable) are presentà CTA neck vs. observation

  • Obtain ct if concern for vascular trauma

    •   If imaging negative observation

o    CXR to rule out pneumo/hemothoax  

Airway

o    If hard signs present, consider intubating early

o    Expanding hematoma can cause airway obstruction; hematemesis can make visualization difficult

o    Prepare (“mark the neck”) for surgical airway if necessary

o    If suspect tracheal injury, then use a .5 size smaller

o    Consider awake intubation or ketamine only

o    To reduce chance of obstruction from muscle relaxation secondary to paralytics

o    Do not vigorously BVM

o    Positive pressure can worsen injury and introduce air into neck space

Breathing

o    Remember lung apices in Zone Iàcan lead to pneumo/hemoX

o    Preform US/obtain CXR

Bleeding

o    Direct pressure  

o    If cant control with pressure, then place a foley catheter through wound and inflate balloon to tamponade as temporizing measure (see image below)

o    But try not to probe/dig around as you can dislodge a clot

Western Trauma Association

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