A patient with sepsis presenting to emergency with electrical storm

Sir, A 35-year-old female presented to our emergency department with altered sensorium and high-grade fever. Routine monitors were applied, which showed ventricular tachycardia (VT) with a heart rate of 180–190 beats/min [Figure 1]. Since the patient had VT at presentation, emergency synchronized Direct current (DC) cardioversion was done with 100 Joules (J) of energy, followed by another one for 100 J. The patient reverted to narrow complex tachycardia and was started on injection amiodarone. In view of the altered sensorium with sepsis, she was intubated and put on ventilatory support, and antibiotics were started.Figure 1: Monomorphic ventricular tachycardia at the time of presentation to the critical care unitThe patient was shifted to the critical care unit. The same day ventricular reoccurred tachycardia with a rate of 130 beats/min [Figure 2] despite amiodarone infusion. The patient was again cardioverted with 100 J of synchronized DC shock, followed by injection lignocaine 100 mg intravenous (IV) bolus and injection amiodarone 150 mg IV over 15 min. Two-dimensional echo revealed a left ventricular ejection fraction of 30%–40%, right ventricular end-systolic pressure of 25 mmHg + right atrial pressure, and moderate-to-severe tricuspid annular plane systolic excursion = 16, with no major structural abnormality except moderate tricuspid regurgitation.Figure 2: Monomorphic ventricular tachycardia on amiodarone infusionOver the next 2 days, the patient had multiple episodes of VT. A cardiology opinion was sought, and injection metoprolol 5 mg IV was added. Following the metoprolol injection, the patient’s heart rate came down to around 70/min [Figure 3]. As the sepsis improved, the ventilatory requirements decreased, and she was extubated after 4 days. Response to treatment was monitored, and normal sinus rhythm was present for 5 consecutive days, following which the patient was shifted to the cardiology ward for further management.Figure 3: Rate and rhythm on injection metoprolol and injection amiodaroneElectrical storm or refractory VT is a condition resulting from electrical instability in the heart, characterized by >3 episodes of hemodynamically destabilizing ventricular fibrillation or VT occurring typically for 24 h.[1] Many reversible triggers have been identified over the past few years, including myocardial ischemia, acute heart failure, drugs, thyrotoxicosis, and electrolyte disturbances.[2] The most common electrocardiogram presentation in a patient with electrical storm is recurrent episodes of monomorphic VT. Treatment of this condition depends on the patient’s presentation. If the patient is unstable, synchronized DC cardioversion with 100 J of energy is required to terminate the arrhythmia. In sable patients, antiarrhythmics such as amiodarone, beta-blockers, lignocaine, and procainamide have a role. Amiodarone is usually the drug of first choice. If VT reoccurs in spite of amiodarone, a beta-blocker may be added. Both cardioselective, i.e., metoprolol, and nonselective, i.e., propranolol, have been tried, and in one case report, propranolol was found to be superior,[3] but we used metoprolol in our patient. That may be true for chronic cardiac failure patients as the beta-1 receptor may get downregulated.[3] However, our patient had no previous history of any cardiac condition, so we decided to use metoprolol. The case presents a new standpoint in the management of refractory VT. Medical therapy with metoprolol and amiodarone was effective in our case. Subsequent stabilization of the patient’s condition might also have played a role in reducing the episodes of VT. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.