Calming the storm - Stellate ganglion block in refractory ventricular arrhythmia in the emergency department

Cease the storm - Successful stellate ganglion block in terminating refractory electrical storm

An electrical storm also known as a ventricular tachycardia storm (VT storm) tends to recur and form a vicious cycle, eventually leading to a refractory electrical storm, refractory to electrical and pharmacological cardioversion. The treatment of refractory VT storm is challenging. Here we discuss the case of a middle-aged gentleman who presented to our emergency department 6 months apart with a refractory VT storm. When all the anti-arrhythmic agents and multiple cardioversion attempts failed in terminating the storm, we attempted ultrasound-guided stellate ganglion block. On both occasions, it successfully terminated the storm. Hence emergency physicians need to be aware of the right technique and timing of stellate ganglion block and ultrasound-guided needle tracking, as it can be a final rescue technique in treating refractory electrical storm in the emergency department.

Current and investigational therapies for the treatment of refractory ventricular fibrillation

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PURPOSE

Esmolol, dual sequential defibrillation, vector change defibrillation, and left stellate ganglion block are presented and reviewed for the treatment of refractory ventricular fibrillation.

SUMMARY

Although no formal definition has been established for refractory ventricular fibrillation, the literature describes it as a pulseless ventricular arrhythmia that persists despite 3 standard defibrillation attempts, administration of amiodarone 300 mg intravenously, and provision of three 1-mg intravenous doses of epinephrine. Evolving literature surrounding resuscitation in this particular subset of cardiac arrest challenges the efficacy of traditional therapies, such as epinephrine, and suggests that other treatment modalities may improve outcomes. Case reports, case series, and small retrospective studies have pointed to benefit when utilizing a variety of therapies, namely, esmolol, dual sequential defibrillation, vector change defibrillation, or left stellate ganglion block, in patients with refractory ventricular fibrillation arrest.

CONCLUSION

A mounting, although limited, body of evidence suggests that esmolol, dual sequential defibrillation, vector change defibrillation, or left stellate ganglion block may be effective at terminating refractory ventricular fibrillation and improving patient outcomes. Further evidence is required before these therapies can be adopted as standard practice; however, as key members of the code response team, it is imperative for pharmacists to be familiar with the supporting evidence, safety considerations, and logistical challenges of utilizing these treatments during arrest.