A 58-year-old post-anterior STEMI on the CCU has had 4 episodes of VF in the last hour, each requiring DC shock. He is now intubated. How do you manage VT/VF storm?

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This is **electrical storm** — ESC 2022 defines it as **≥3 sustained ventricular arrhythmias in 24 hours**, a true cardiology emergency with high mortality.

**Immediate priorities (ALS).** For each VF episode: defibrillation, CPR, adrenaline 1 mg every 3–5 minutes after the third shock, **amiodarone 300 mg IV** after the third shock. Confirm tube position, capnography.

**Reverse the reversibles.** Send urgent ABG, U&E, magnesium, troponin. Aim K+ 4.5–5.0, Mg ≥1.0. Treat acidosis. Review the ECG between episodes for ischaemia, QT prolongation, Brugada-type changes; review the drug chart for QT-prolonging agents.

**Suppress the sympathetic storm — the key therapeutic lever.** Storm is sympathetically driven. **IV beta-blockade** (esmolol infusion 50–300 mcg/kg/min, or propranolol 1 mg boluses) is first-line per ESC. Add an **amiodarone loading infusion (900–1200 mg over 24 h)**. Lidocaine 1–1.5 mg/kg can be added if amiodarone alone fails, particularly in ischaemic storm.

**Deepen sedation.** With ITU, deepen sedation, consider **propofol and even general anaesthesia** to obtund the sympathetic surge.

**Treat the substrate.** Urgent **coronary angiography** to exclude stent thrombosis or new ischaemia — this is the commonest substrate post-STEMI. **Bedside echo** for LV function, mechanical complications.

**Escalate.** Phone the on-call electrophysiologist and the tertiary centre **now**. Options include **catheter ablation of the VT substrate, stellate ganglion blockade, and VA-ECMO as a bridge**. INTERMACS / shock-team conversation in parallel.

**Communication and ethics.** Honest update to the family; in a patient with recurrent storm post-MI, a **ceiling-of-care discussion** is appropriate — including ICD planning if he survives.

Refractory VT/VF storm on CCU

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