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cardio.cardiogenic-shock.brugada-storm.v1PRODUCTION
cardio.cardiogenic-shock.brugada-storm.v1

Cardiogenic shock — Brugada syndrome electrical storm

cardiologyacuteadult
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Recognize Brugada electrical storm with shock — channelopathy + Type 1 ECG + storm-defining ≥3 VT/VF in 24 h + hemodynamic collapse; this is a primary electrical disease, NOT ischemic

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Brugada storm with CS overlay confirmed

Patient inputs (14)

Brugada most often manifests age 30–50 y, male predominance ~8:1; informs ICD eligibility decision

Male predominance ~8:1 (testosterone effect on Ito); influences risk stratification

Compensatory tachy / brady + pre-arrest state; influences isoproterenol titration target (HR 90–110 typical target)

End-organ damage marker; eGFR for quinidine dose adjustment

STOP all Na-channel blockers (lidocaine, procainamide, flecainide, propafenone, cocaine); www.brugadadrugs.org curated avoid-list

Hypokalemia worsens storm (K target ≥4.0); aggressive replacement mandatory

Hypomagnesemia precipitates polymorphic VT; replace to ≥2.0

Differentiate from ischemic cause of polymorphic VT; usually negative or modest in primary Brugada storm

Type 1 Brugada pattern in V1–V3 (coved ST ≥2 mm + T-wave inversion) — diagnostic anchor; serial ECGs to track ST evolution; high V1–V2 lead placement (2nd–3rd ICS) increases sensitivity

STRUCTURALLY NORMAL HEART expected (Brugada is channelopathy, not cardiomyopathy); rules out ischemic / structural cause of polymorphic VT

SCAI 2022 staging baseline + vasopressor titration; storm with hemodynamic collapse defines CS overlay

Fever is the MOST COMMON modifiable trigger of Brugada storm; aggressive antipyresis + ice mandatory

SCAI 2022 staging + perfusion; CardShock prognostication (Harjola EHJ 2015 PMID 26333869)

Family history <45 y SCD raises ICD threshold; SCN5A mutation panel offered to first-degree relatives

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Severity triggers (5)

5 need judgement
  • informationallife_threateninginadvertent_na_channel_blocker_exposure_in_brugada
    Inadvertent administration of Na-channel-blocking drug (lidocaine, procainamide, flecainide, propafenone, cocaine, some psychotropics) in known Brugada patient → STOP drug + isoproterenol if storm develops + reverse Type 1 ECG accentuation
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningfever_triggered_storm_in_brugada
    Fever (T > 38°C) precipitating polymorphic VT / VF storm in known or new Brugada patient — most common modifiable trigger; aggressive antipyresis + cooling
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrecurrent_icd_shocks_brugada_storm
    Recurrent ICD shocks (≥3 in 24 h) in Brugada patient — defines electrical storm; emergent EP for shock burden management + storm suppression
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrefractory_brugada_storm_needs_substrate_ablation
    Refractory Brugada storm despite isoproterenol + quinidine + trigger reversal — emergent referral for catheter ablation of RVOT epicardial substrate (Nademanee technique)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverefamily_history_sudden_death_with_type1_brugada
    Family history of sudden death <45 y in patient with spontaneous Type 1 Brugada ECG — HRS 2017 Class IIa for ICD; cascade testing of first-degree relatives
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Brugada electrical storm with CS — isoproterenol + quinidine + trigger reversal; AVOID ALL Na-channel blockers; aggressive antipyresis; ICD/ablation pathway
axis: brugada_storm_phenotype
Selected axis "Brugada electrical storm with CS — isoproterenol + quinidine + trigger reversal; AVOID ALL Na-channel blockers; aggressive antipyresis; ICD/ablation pathway" by default fallback (first axis)
  • isoproterenol
    first line
    beta1_agonist
    1–3 µg/min IV titrate • IV • continuous; titrate to HR 90–110 + storm suppression
    triggers: brugada_storm_active, recurrent_polymorphic_vt_in_brugada
    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
    rxcui 6054
  • quinidine
    first line
    class_ia_antiarrhythmic_with_ito_blockade
    1–2 g/d PO loading then 600–1200 mg/d maintenance (target level 2–5 µg/mL) • PO • q6h after load
    triggers: brugada_storm_refractory_to_isoproterenol_alone, long_term_storm_prevention_bridge_to_ablation
    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
    rxcui 9068
  • acetaminophen
    first line
    antipyretic
    650–1000 mg PO/PR/IV q4–6 h • PO/PR/IV • q4–6 h scheduled while febrile
    triggers: fever_in_brugada_patient, storm_with_temperature_above_38c
    Fever is the MOST COMMON modifiable Brugada storm trigger; aggressive antipyresis + surface cooling mandatory; HRS 2017
    rxcui 161
  • norepinephrine
    first line
    vasopressor_alpha
    0.05–0.5 µg/kg/min IV titrate • IV • continuous; titrate to MAP ≥65
    triggers: cs_overlay_on_brugada_storm, sbp_lt_90_persistent
    SOAP-II PMID 20200382 — first-line in CS; supports MAP while isoproterenol handles arrhythmia; α-1 effect does not adversely affect Brugada substrate
    rxcui 7512
  • potassium chloride
    first line
    electrolyte
    20–40 mEq IV/PO; target K ≥4.5 • IV/PO • PRN until K ≥4.5
    triggers: k_below_4_in_brugada_storm, recurrent_polymorphic_vt
    Hypokalemia worsens Brugada storm; aggressive K replacement to ≥4.5 mandatory
    rxcui 8591
  • magnesium sulfate
    first line
    electrolyte
    2 g IV bolus then 2 g/h infusion • IV • continuous; target Mg ≥2.0
    triggers: mg_below_2_in_brugada_storm, polymorphic_vt_episode
    Standard polymorphic VT supportive therapy; replace to ≥2.0; safer than additional antiarrhythmics in Brugada
    rxcui 6585

outpatient playbook — drug actions (3)

  1. 1. continue oral quinidine maintenance
    rxcui 9068
    600–1200 mg/d (level 2–5 µg/mL) • PO • q6h
    trigger: Storm-prone phenotype
    HRS 2017 Class IIa long-term storm prevention; Belhassen registry data
  2. 2. consider catheter ablation if storm-prone despite quinidine
    EP referral • n/a • one-time procedure
    trigger: Recurrent storm despite quinidine
    Nademanee 2011 PMID 21571989 — RVOT epicardial substrate ablation
  3. 3. continue lifelong avoidance of Na-channel blockers
    patient education + curated drug list (www.brugadadrugs.org) • n/a • lifelong
    trigger: Brugada diagnosis
    HRS 2017

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: ECG Type 1 Brugada (V1–V3 coved ST elevation ≥2 mm + T-wave inversion) + sustained polymorphic VT / VF episodes — electrical storm with shock physiology; 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.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Cardiogenic shock — Brugada syndrome electrical storm** (cardio.cardiogenic-shock.brugada-storm.v1).
Scope: Recognize Brugada electrical storm with shock — channelopathy + Type 1 ECG + storm-defining ≥3 VT/VF in 24 h + hemodynamic collapse; this is a primary electrical disease, NOT ischemic

No severity triggers fired against current inputs.

Plan

Regimen axis: **Brugada electrical storm with CS — isoproterenol + quinidine + trigger reversal; AVOID ALL Na-channel blockers; aggressive antipyresis; ICD/ablation pathway**.
1. isoproterenol 1–3 µg/min IV titrate IV continuous; titrate to HR 90–110 + storm suppression (beta1_agonist, first line) — 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
2. quinidine 1–2 g/d PO loading then 600–1200 mg/d maintenance (target level 2–5 µg/mL) PO q6h after load (class_ia_antiarrhythmic_with_ito_blockade, first line) — 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
3. acetaminophen 650–1000 mg PO/PR/IV q4–6 h PO/PR/IV q4–6 h scheduled while febrile (antipyretic, first line) — Fever is the MOST COMMON modifiable Brugada storm trigger; aggressive antipyresis + surface cooling mandatory; HRS 2017
4. norepinephrine 0.05–0.5 µg/kg/min IV titrate IV continuous; titrate to MAP ≥65 (vasopressor_alpha, first line) — SOAP-II PMID 20200382 — first-line in CS; supports MAP while isoproterenol handles arrhythmia; α-1 effect does not adversely affect Brugada substrate
5. potassium chloride 20–40 mEq IV/PO; target K ≥4.5 IV/PO PRN until K ≥4.5 (electrolyte, first line) — Hypokalemia worsens Brugada storm; aggressive K replacement to ≥4.5 mandatory
6. magnesium sulfate 2 g IV bolus then 2 g/h infusion IV continuous; target Mg ≥2.0 (electrolyte, first line) — Standard polymorphic VT supportive therapy; replace to ≥2.0; safer than additional antiarrhythmics in Brugada

Setting playbook (outpatient) — Long-term EP / inherited-arrhythmia clinic — ICD interrogation q3 mo; quinidine maintenance + level monitoring; family screening completion + genetic counseling; lifelong drug-avoidance education; consider catheter ablation for storm-prone phenotype (Nademanee technique)
7. continue oral quinidine maintenance 600–1200 mg/d (level 2–5 µg/mL) PO q6h — Storm-prone phenotype (HRS 2017 Class IIa long-term storm prevention; Belhassen registry data)
8. consider catheter ablation if storm-prone despite quinidine EP referral n/a one-time procedure — Recurrent storm despite quinidine (Nademanee 2011 PMID 21571989 — RVOT epicardial substrate ablation)
9. continue lifelong avoidance of Na-channel blockers patient education + curated drug list (www.brugadadrugs.org) n/a lifelong — Brugada diagnosis (HRS 2017)

Non-pharmacologic actions:
- EP / inherited-arrhythmia clinic q3 mo
- Family genetic counseling + first-degree relative ECG screening (provocative ajmaline/flecainide ONLY in genetics center under EP supervision)
- Lifestyle — moderate alcohol; aggressive fever management; avoid large meals (vagal trigger); medic-alert bracelet
- ICD generator / lead surveillance per device clinic

AVOID / contraindication checks:
- Lidocaine_AVOID_in_Brugada_storm (Na channel blocker; can trigger storm — paradoxical)
- Procainamide_AVOID_in_Brugada_storm (Na channel blocker; PROCAMIO general algorithm does NOT apply in Brugada)
- Flecainide_AVOID_in_Brugada_storm (DIAGNOSTIC for Brugada at low dose; LETHAL at therapeutic dose)
- Propafenone_AVOID_in_Brugada_storm (Na channel blocker — same class IC as flecainide)
- Cocaine_AVOID_in_Brugada (Na channel blocking effect; can trigger storm)
- Amiodarone_relative_AVOID_in_Brugada_storm (variable / unproven benefit; can prolong QT further)
- Beta_blocker_AVOID_acute_Brugada_storm (removes β 1 stabilization; opposite of LQT — different storm pharmacology)
- Psychotropics_with_na_channel_blocking_review_before_use (TCAs, some SSRIs; consult www.brugadadrugs.org curated list)

Monitoring

Regimen monitoring:
- continuous telemetry with high V1 V2 lead placement 2nd 3rd ICS (Brugada-sensitive lead positioning)
- serial ECG q4-6h initially (track ST evolution + storm suppression)
- isoproterenol titration to HR 90-110 and ST normalization (HRS 2017)
- quinidine level q24h target 2-5 mcg per mL (therapeutic window)
- arterial line continuous BP (CS support)
- lactate q1-2h (CardShock prognostication)
- UOP hourly (perfusion marker)
- electrolytes q4-6h until K above 4.5 and Mg above 2 (mandatory)
- temperature q1h aggressive antipyresis target under 37 (fever is top trigger)

Setting (outpatient) monitoring:
- q3 mo ICD interrogation + quinidine level
- Annual ECG
- Family screening progress documentation

Follow-up plan: 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
- Close-out criterion: Long-term EP plan + family screening + drug-avoidance education complete

Monitoring phase: Continuous telemetry with Brugada lead placement (high V1–V2); A-line; central line; serial ECGs q4–6 h initially; lactate clearance; UOP; isoproterenol titration to target HR 90–110 + storm suppression; quinidine level monitoring (target 2–5 µg/mL)

Disposition

Current setting: outpatient — Long-term EP / inherited-arrhythmia clinic — ICD interrogation q3 mo; quinidine maintenance + level monitoring; family screening completion + genetic counseling; lifelong drug-avoidance education; consider catheter ablation for storm-prone phenotype (Nademanee technique)

Disposition criteria:
- Stable on long-term EP regimen with ICD + quinidine ± ablation; lifelong follow-up

Escalation triggers (move to higher acuity):
- Recurrent ICD shocks → emergent EP + ablation evaluation
- New arrhythmia (AF, VT) → EP for programming + drug review
- Quinidine intolerance / toxicity → ablation pathway
- Family member positive screening → cascade testing + EP referral

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Inadvertent administration of Na-channel-blocking drug (lidocaine, procainamide, flecainide, propafenone, cocaine, some psychotropics) in known Brugada patient → STOP drug + isoproterenol if storm develops + reverse Type 1 ECG accentuation
- [LIFE_THREATENING] Fever (T > 38°C) precipitating polymorphic VT / VF storm in known or new Brugada patient — most common modifiable trigger; aggressive antipyresis + cooling
- [LIFE_THREATENING] Recurrent ICD shocks (≥3 in 24 h) in Brugada patient — defines electrical storm; emergent EP for shock burden management + storm suppression

Citations

- 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) [PMID:28219760](https://pubmed.ncbi.nlm.nih.gov/28219760/)
- Cited evidence (PMID 21571989) [PMID:21571989](https://pubmed.ncbi.nlm.nih.gov/21571989/)
- Cited evidence (PMID 35718438) [PMID:35718438](https://pubmed.ncbi.nlm.nih.gov/35718438/)
- Cited evidence (PMID 38587234) [PMID:38587234](https://pubmed.ncbi.nlm.nih.gov/38587234/)
- Cited evidence (PMID 20200382) [PMID:20200382](https://pubmed.ncbi.nlm.nih.gov/20200382/)

Last reconciled with current guidelines: 2026-05-15.
References
  • 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) — PMID:28219760
  • Cited evidence (PMID 21571989) — PMID:21571989
  • Cited evidence (PMID 35718438) — PMID:35718438
  • Cited evidence (PMID 38587234) — PMID:38587234
  • Cited evidence (PMID 20200382) — PMID:20200382