This handout is for cardiogenic shock — brugada syndrome electrical storm. Your care team identified this based on: ecg type 1 brugada (v1–v3 coved st elevation ≥2 mm + t-wave inversion) + sustained polymorphic vt / vf episodes — electrical storm with shock physiology.
Other reasons your team may use this plan: recurrent icd shocks (≥3 in 24 h) in known brugada patient — electrical storm; assess for fever / na-channel-blocker exposure trigger; syncope or aborted scd in patient with spontaneous or drug-induced type 1 brugada ecg; family history of sudden death <45 y; fever (t >38°c) precipitating polymorphic vt in known brugada patient — most common storm trigger.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| isoproterenol | 1–3 µg/min IV titrate | IV | continuous; titrate to HR 90–110 + storm suppression | HRS 2017 (PMID 28219760) — paradoxical β-1 agonist that suppresses Brugada storm by augmenting L-type Ca current (ICa-L); FIRST-LINE for storm; titrate to HR 90–110 and ECG ST normalization |
| quinidine | 1–2 g/d PO loading then 600–1200 mg/d maintenance (target level 2–5 µg/mL) | PO | q6h after load | Belhassen 2004/2015 — ONLY Na-channel blocker that helps in Brugada because it ALSO blocks Ito (transient outward K current); reduces phase-2 dispersion driving reentry; HRS 2017 Class IIa for storm + bridge to ablation |
| acetaminophen | 650–1000 mg PO/PR/IV q4–6 h | PO/PR/IV | q4–6 h scheduled while febrile | Fever is the MOST COMMON modifiable Brugada storm trigger; aggressive antipyresis + surface cooling mandatory; HRS 2017 |
| norepinephrine | 0.05–0.5 µg/kg/min IV titrate | IV | continuous; titrate to MAP ≥65 | SOAP-II PMID 20200382 — first-line in CS; supports MAP while isoproterenol handles arrhythmia; α-1 effect does not adversely affect Brugada substrate |
| potassium chloride | 20–40 mEq IV/PO; target K ≥4.5 | IV/PO | PRN until K ≥4.5 | Hypokalemia worsens Brugada storm; aggressive K replacement to ≥4.5 mandatory |
| magnesium sulfate | 2 g IV bolus then 2 g/h infusion | IV | continuous; target Mg ≥2.0 | Standard polymorphic VT supportive therapy; replace to ≥2.0; safer than additional antiarrhythmics in Brugada |
Plan: Brugada electrical storm with CS — isoproterenol + quinidine + trigger reversal; AVOID ALL Na-channel blockers; aggressive antipyresis; ICD/ablation pathway
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
EP / inherited-arrhythmia clinic follow-up 1–4 wks; ICD interrogation at 1 wk, 1 mo, then q3 mo; family genetic counseling + first-degree relative ECG screening (consider provocative ajmaline / flecainide test in genetics center ONLY); www.brugadadrugs.org avoid-list patient education; long-term oral quinidine if storm-prone or bridge-to-ablation
Guideline: HRS 2017 Inherited Arrhythmia Syndromes Expert Consensus (Al-Khatib PMID 28219760); ESC 2022 VA / SCD prevention; AHA 2020 ACLS; SCAI 2022 CS staging (Naidu PMID 35718438)