**Introduction/Hypothesis**
Electrical storm (ES) in patients with ICD is commonly known as 3 or more sustained ventricular tachycardia (VT) episodes within 24 hours that fail to respond to appropriate therapies, including antitachycardia pacing or shock. Although quite common, ES is a life-threatening medical emergency that can lead to imminent morbidity and death. The incidence is approximately 10-25% per year during the follow-up period in patients with ICDs. Prognosis is extremely poor as clinical trials identified ES as a significant independent risk factor for cardiac, non-sudden death, and patients with ES had an approximately 18-fold increased risk of death within the first 3 months.

**Methods**
Information obtained through electronic medical record.

**Results**
Patient is a 55-year-old male with medical history of chronic ischemic cardiomyopathy, heart failure with reduced ejection fraction, hypertension, hyperlipidemia, paroxysmal atrial fibrillation, and AV node ablation with CRT in place who presented to the hospital after noting palpitations and diaphoresis upon waking up. While in the emergency department, heart rate was 161, blood pressure was 108/88, oxygen saturation was 98% on room air. On examination, the patient was alert but appeared to be in acute distress. Cardiac auscultation revealed tachycardia with irregular rhythm. EKG revealed wide complex tachycardia, 160 beats per minute. Labs consisted of arterial pH of 7.27, lactic acidosis of 6.3, and unremarkable serial high sensitivity troponins. Initial management in the ED was unsuccessful with IV rate controlling agents, IV fluids, and cardioversion. He was admitted to the cardiac ICU on an amiodarone infusion. Sustained ventricular tachycardia was noted upon interrogation of CRT device. Multiple attempts at antitachycardia pacing and shock were unsuccessful. Lidocaine was initiated. The patient was elected for deep sedation and intubated for airway protection. Beta blockers were also initiated to minimize sympathetic input. Vasopressors were eventually initiated due to cardiogenic shock. ES subsequently remained quiescent on these medications. Ischemic evaluation was warranted at that time; however, the patient was unstable to undergo cardiac catheterization. He was transferred to a higher level of care for potential management including stellate ganglion block or ventricular tachycardia ablation under extracorporeal membrane oxygenation (ECMO). Unfortunately, the patient was made DNR and transpired after sustained ventricular tachycardia.

**Conclusion**
Management of ES can be extremely challenging given the limited available evidence from small studies that were only conducted in retrospect. Recognizing the triggers of electrical storms and moving the focus of future studies towards prevention may be the key to more effectively reducing morbidity and mortality.



The Never Ending Storm