WEBVTT 00:00:07.880 --> 00:00:10.759 You're in the bay. Once you get over to the bed, 00:00:10.919 --> 00:00:13.560 we'll give you the story. Everything's going 00:00:13.560 --> 00:00:17.339 to happen super fast. Welcome to the emergency 00:00:17.339 --> 00:00:43.719 room. Alright guys, so this right here is going 00:00:43.719 --> 00:00:48.609 to be over dysrhythmia arrhythmias I don't know 00:00:48.609 --> 00:00:52.090 the difference between a dysrhythmia or an arrhythmia 00:00:52.090 --> 00:00:54.630 If there is a difference, please, you know, let 00:00:54.630 --> 00:00:59.990 me know or You know it for me. It doesn't really 00:00:59.990 --> 00:01:03.469 matter. You know, I use the terms interchangeably 00:01:03.469 --> 00:01:08.590 But what I will say is I do not know What arrhythmia 00:01:08.590 --> 00:01:10.750 is they're going to go over in this particular 00:01:10.750 --> 00:01:13.629 episode because I haven't listened to it yet 00:01:13.629 --> 00:01:17.400 but Um, we can just kind of do like a little 00:01:17.400 --> 00:01:21.780 overview real quick. Um, so your easy ones are 00:01:21.780 --> 00:01:25.780 going to be v fib just look like a bunch of squiggles 00:01:25.780 --> 00:01:30.840 on the EKG paper or on the lead strip. And then 00:01:30.840 --> 00:01:35.480 you have fine v fib, um, fine v fib. If you're 00:01:35.480 --> 00:01:38.980 taking like an AHA course, it will literally 00:01:38.980 --> 00:01:42.140 look like a systole, but they'll have a little 00:01:42.140 --> 00:01:45.040 bit of like a little wave in there. you know, 00:01:45.040 --> 00:01:46.519 and they're going to be like, oh, that's coarse. 00:01:46.780 --> 00:01:49.140 That's fine. VFib. And you're like, it's asystole, 00:01:50.000 --> 00:01:52.519 you know, but they're going to call it, you know, 00:01:52.680 --> 00:01:57.280 fine VFib. And for the AHA is concerned, asystole 00:01:57.280 --> 00:02:01.900 is quite literally a flat line. But in an emergency 00:02:01.900 --> 00:02:05.180 situation, fine VFib and asystole are going to 00:02:05.180 --> 00:02:10.599 look the same. But you have VFib, which is like 00:02:10.599 --> 00:02:12.400 I said, it's going to be just that squiggle line 00:02:12.400 --> 00:02:16.469 on the EKG paper. then you have fine v fib it's 00:02:16.469 --> 00:02:20.409 just going to be smaller squiggles on the on 00:02:20.409 --> 00:02:24.629 the um ekg paper and then you have your v tac 00:02:24.629 --> 00:02:26.750 which is just going to look like big tombstones 00:02:26.750 --> 00:02:30.370 or the mcdonald sign over and over again and 00:02:30.370 --> 00:02:33.310 then you have torsades which you will get you 00:02:33.310 --> 00:02:37.469 know that really really big v tac And then it 00:02:37.469 --> 00:02:41.270 shrinks down into small VTAC or V fib and then 00:02:41.270 --> 00:02:44.590 it shoots back out VTAC again and then V fib 00:02:44.590 --> 00:02:47.150 and then VTAC. At least that's the way it looks 00:02:47.150 --> 00:02:51.090 on the EKG paper. Again, I'm not a cardiologist 00:02:51.090 --> 00:02:53.030 by any means, so I don't know what the hell is 00:02:53.030 --> 00:02:56.569 actually happening in torsades. All I know is 00:02:56.569 --> 00:02:58.050 that you're going to try to slow that shit down 00:02:58.050 --> 00:03:00.409 with some mag and then hope for the best with 00:03:00.409 --> 00:03:07.000 your other ACLS drugs. And then you will have 00:03:07.000 --> 00:03:11.960 your a fib your a fib with RVR now the big thing 00:03:11.960 --> 00:03:15.139 with a fib with RVR is that you're gonna have 00:03:15.139 --> 00:03:21.900 a fib and then in a run of RVR you're gonna have 00:03:21.900 --> 00:03:27.639 a very rapid, you know QRS complex, you know 00:03:27.639 --> 00:03:30.500 that are really really close together and then 00:03:30.500 --> 00:03:33.319 you'll get your rhythm back, you know of your 00:03:33.319 --> 00:03:37.270 a fib, which is that irregular regular, you know, 00:03:37.349 --> 00:03:40.490 kind of pattern. And then your RVR again will 00:03:40.490 --> 00:03:44.189 be like a really short squished together QRS 00:03:44.189 --> 00:03:47.430 complex next to each other, maybe three, four 00:03:47.430 --> 00:03:50.090 or five of them. And then it shoots back out 00:03:50.090 --> 00:03:53.270 to your normal rhythm. And then you have a flutter. 00:03:53.909 --> 00:03:59.849 Now, not too long ago in the ER, I heard the 00:03:59.849 --> 00:04:03.650 term a flutter with RVR. I don't know if that's 00:04:03.650 --> 00:04:07.409 a thing. But if it is then you're going to be 00:04:07.409 --> 00:04:09.110 looking for the same thing you're going to be 00:04:09.110 --> 00:04:11.250 looking for your sawtooth pattern in between 00:04:11.250 --> 00:04:15.729 your QRS complexes and then I'm assuming your 00:04:15.729 --> 00:04:18.689 QRS complexes are going to squish together and 00:04:18.689 --> 00:04:21.069 you got you're going to get like four or five 00:04:21.069 --> 00:04:23.949 six beats and then it'll shoot back out to your 00:04:23.949 --> 00:04:28.069 normal rhythm and then shoot back down in and 00:04:28.069 --> 00:04:30.889 to those really tight QRS complexes and then 00:04:30.889 --> 00:04:34.810 I guess shoot back out to like the regular irregular 00:04:34.810 --> 00:04:39.410 rhythm and then that's your a flutter and You 00:04:39.410 --> 00:04:43.910 have your NSR Which is your normal sinus? And 00:04:43.910 --> 00:04:47.170 then you have Brady and then you have your tacky 00:04:47.170 --> 00:04:50.550 it did I don't know if they're going to get into 00:04:50.550 --> 00:04:57.410 heart blocks in this particular Episode but the 00:04:57.410 --> 00:05:01.389 easiest way to tell a heart block is your heart 00:05:01.389 --> 00:05:05.310 blocks are going to be predicated by your P wave 00:05:05.310 --> 00:05:08.810 and everything with heart blocks is going to 00:05:08.810 --> 00:05:13.089 be P P wave related. So your first degree heart 00:05:13.089 --> 00:05:16.670 block, you're going to be having your P wave, 00:05:16.750 --> 00:05:20.790 which is going to be a little bit further away 00:05:20.790 --> 00:05:23.730 from your QRS complex than you would like it 00:05:23.730 --> 00:05:27.740 to be. I can't remember the exact numbers because 00:05:27.740 --> 00:05:31.920 I don't have an EKG ruler in front of me or the 00:05:31.920 --> 00:05:36.300 criteria, but your P wave will be completely, 00:05:36.300 --> 00:05:39.259 you know, kind of move back a little bit. And 00:05:39.259 --> 00:05:42.319 that right there will be your first degree. Your 00:05:42.319 --> 00:05:45.600 second degree type one, if I'm not mistaken, 00:05:45.819 --> 00:05:51.060 is your Mobitz one. If I'm not mistaken, I should 00:05:51.060 --> 00:05:52.819 probably look this up before I give you guys 00:05:52.819 --> 00:05:56.069 the wrong. Information, let me pause real quick. 00:05:56.089 --> 00:06:01.250 Okay, just checked it. So Mo bits one is your 00:06:01.250 --> 00:06:07.850 winking Bach your winky Bach Arrhythmia right 00:06:07.850 --> 00:06:13.050 heart block and so it is the Arrhythmia that 00:06:13.050 --> 00:06:17.449 has that little Rhyme to it wider wider wider 00:06:17.449 --> 00:06:21.589 drop then you have a winky Bach Again, you're 00:06:21.589 --> 00:06:24.509 looking at your P wave All these heart blocks 00:06:24.509 --> 00:06:27.149 my little piece of advice to you guys don't over 00:06:27.149 --> 00:06:30.170 complicate this shit It's literally your P wave 00:06:30.170 --> 00:06:34.069 for these heart blocks So with type one or with 00:06:34.069 --> 00:06:36.790 your first degree heart block your P wave is 00:06:36.790 --> 00:06:39.410 sitting a little bit further back from the QRS 00:06:39.410 --> 00:06:43.750 complex Right in your mo bits one your heart 00:06:43.750 --> 00:06:47.750 your second degree heart block type one is your 00:06:47.750 --> 00:06:50.569 P wave will be normal and then it will get further 00:06:50.569 --> 00:06:54.300 away from the from the QRS complex and then further 00:06:54.300 --> 00:06:57.339 away from the complex again. And then you'll 00:06:57.339 --> 00:06:59.819 have a drop beat and then your P wave will show 00:06:59.819 --> 00:07:03.959 back up right next to your QRS complex and then 00:07:03.959 --> 00:07:06.620 start getting wider and wider out from the QRS 00:07:06.620 --> 00:07:10.160 complex before another beat drops. Okay, that's 00:07:10.160 --> 00:07:13.980 your type one for Mobitz. And then your type 00:07:13.980 --> 00:07:18.879 two is your P wave will stay the same, whether 00:07:18.879 --> 00:07:23.319 it's further or closer to your QRS complex is 00:07:23.319 --> 00:07:28.759 irrelevant. But it will be it'll be stationary. 00:07:28.980 --> 00:07:32.160 And then on your EKG paper, you'll just have 00:07:32.160 --> 00:07:35.660 a drop beat just out of nowhere. Right. And then 00:07:35.660 --> 00:07:38.699 you'll get your beat back. And then the P wave 00:07:38.699 --> 00:07:42.459 will be right where it needs to be. OK. And then 00:07:42.459 --> 00:07:45.860 your third degree heart block is going to be 00:07:45.860 --> 00:07:50.519 your P wave is doing its own, its own damn thing. 00:07:51.120 --> 00:07:54.060 Right. So the atria are just doing their own 00:07:54.060 --> 00:07:56.360 thing. They're not synchronized with their ventricles 00:07:56.360 --> 00:08:00.319 at all. So they're contracting without any coordination 00:08:00.319 --> 00:08:04.259 with the ventricles. Right. And so your P wave 00:08:04.259 --> 00:08:08.680 will be where it's supposed to be. It'll be like 00:08:08.680 --> 00:08:12.430 in this random ass spot. between your T wave 00:08:12.430 --> 00:08:16.769 and your QRS complex or hell, it could be hidden 00:08:16.769 --> 00:08:20.810 in the T wave. And what it will look like is 00:08:20.810 --> 00:08:24.310 that you'll have this little notch up or this 00:08:24.310 --> 00:08:28.329 little spike in your T wave and then you'll have 00:08:28.329 --> 00:08:32.549 your QRS complex or hell your your P wave could 00:08:32.549 --> 00:08:37.649 be hidden in the QRS complex, which is very difficult 00:08:37.649 --> 00:08:42.000 to kind of see. On the EKG paper, you might get 00:08:42.000 --> 00:08:46.659 lucky and see like a notch, you know, in your. 00:08:46.659 --> 00:08:51.059 What is your our wave? You might get a little 00:08:51.059 --> 00:08:54.440 higher of a notch than everywhere else, you know, 00:08:54.480 --> 00:08:58.700 but or it might look like like a bundle branch 00:08:58.700 --> 00:09:01.299 block. So you might get like a little cat ear 00:09:01.299 --> 00:09:06.700 looking thing or maybe even a W in your. What 00:09:06.700 --> 00:09:12.600 is that? QRS, I guess your Q your Q wave Whichever 00:09:12.600 --> 00:09:15.299 one is the bottom one that comes down. Damn it. 00:09:15.299 --> 00:09:19.580 It comes down Right. You might get a W with that, 00:09:19.700 --> 00:09:21.940 right? And so you might get fortunate enough 00:09:21.940 --> 00:09:24.840 to get that Right, but typically your P wave 00:09:24.840 --> 00:09:27.440 is going to be doing its own fucking thing, right? 00:09:27.440 --> 00:09:30.419 And it's not going to follow any sort of logic. 00:09:30.539 --> 00:09:33.200 It's just going to be doing its own thing, you 00:09:33.200 --> 00:09:36.120 know And so that's how you know that you're in 00:09:36.120 --> 00:09:39.240 a third degree heart block, which is your more 00:09:39.240 --> 00:09:44.320 serious heart block. I will say the rarest ones 00:09:44.320 --> 00:09:47.879 that I've seen is a type one, your winky Bach, 00:09:48.360 --> 00:09:52.460 right? Where it just gets wider and wider and 00:09:52.460 --> 00:09:55.039 then drops, right? I've only seen it once in 00:09:55.039 --> 00:09:59.200 clinical practice. And me and the hospitalist 00:09:59.200 --> 00:10:02.840 were like, what is a type one? And we were all 00:10:02.840 --> 00:10:05.429 excited. and the patient had no idea what the 00:10:05.429 --> 00:10:07.909 hell we were talking about because it's so uncommon 00:10:07.909 --> 00:10:13.889 to find um but so with your heart blocks don't 00:10:13.889 --> 00:10:18.149 over complicate the shit it is all going to be 00:10:18.149 --> 00:10:23.149 determined on your p -wave okay again your p 00:10:23.149 --> 00:10:25.730 -wave is going to determine what type of heart 00:10:25.730 --> 00:10:30.289 block you have all right So don't be looking 00:10:30.289 --> 00:10:32.950 at your QRS complex. Don't be looking at your 00:10:32.950 --> 00:10:36.190 fucking T wave. Everything about heart blocks 00:10:36.190 --> 00:10:41.129 is going to be in your P wave as in Papa your 00:10:41.129 --> 00:10:47.289 P wave. Okay. And then, um, again, I don't know 00:10:47.289 --> 00:10:48.990 if they're going to be getting into these, but 00:10:48.990 --> 00:10:53.330 you have your bundle branch blocks. So again, 00:10:53.330 --> 00:10:55.929 I don't know, like lead one, two, three, your 00:10:55.929 --> 00:11:00.159 V one V two. V3, you know, in your AVR, I think 00:11:00.159 --> 00:11:03.500 it's SVR. Like, I don't know where you're going 00:11:03.500 --> 00:11:05.779 to find these at. Like, I know that, you know, 00:11:05.879 --> 00:11:07.860 nurse practitioners and stuff like that, I can 00:11:07.860 --> 00:11:11.259 look in your PAs and your MDs will look at the 00:11:11.259 --> 00:11:13.799 strip and they'll like compare Lee wanted to 00:11:13.799 --> 00:11:17.899 to like AVR or something like that. But for our 00:11:17.899 --> 00:11:22.399 intensive purposes for our in school is your 00:11:22.399 --> 00:11:25.179 left and right bundle branch blocks. If I'm not 00:11:25.179 --> 00:11:28.200 mistaken. I believe. Let me check before I give 00:11:28.200 --> 00:11:30.960 you guys wrong information. So with your left 00:11:30.960 --> 00:11:35.460 bundle branch block, your EKG paper might show 00:11:35.460 --> 00:11:40.419 like a little Batman looking thing where your 00:11:40.419 --> 00:11:43.779 QRS complex looks like either a cat or a Batman, 00:11:44.639 --> 00:11:47.779 where there's like two peaks, you know, at the 00:11:47.779 --> 00:11:50.179 top of the QRS complex. I'd have like two peaks 00:11:50.179 --> 00:11:55.129 or. your QRS complex on the part that goes down 00:11:55.129 --> 00:11:59.169 will look like a W. Okay. And then on your right 00:11:59.169 --> 00:12:04.289 bundle branch block, like when you're getting 00:12:04.289 --> 00:12:10.169 ready to repolarize, go for the ventricles to 00:12:10.169 --> 00:12:14.269 repolarize to get your T wave, that little space 00:12:14.269 --> 00:12:17.710 at the end of the QRS complex before you get 00:12:17.710 --> 00:12:21.019 to the T wave will look like a U. like it'll 00:12:21.019 --> 00:12:23.659 dip down and make like a U or you might even 00:12:23.659 --> 00:12:29.860 get an inverted T wave right and then um they 00:12:29.860 --> 00:12:33.240 might go over you know potassium your peak T 00:12:33.240 --> 00:12:37.220 waves just remember as the more and more potassium 00:12:37.220 --> 00:12:40.820 the body has it'll start really throwing off 00:12:40.820 --> 00:12:44.399 the the heart's ability to regulate itself and 00:12:44.399 --> 00:12:47.779 so you can get these massive peak T waves to 00:12:47.779 --> 00:12:51.490 the point to where The car is complex completely 00:12:51.490 --> 00:12:55.690 fades away as the potassium gets higher to where 00:12:55.690 --> 00:12:59.870 the potassium gets so high. That the only thing 00:12:59.870 --> 00:13:02.450 you're going to look at is a t -wave and at that 00:13:02.450 --> 00:13:04.409 point you're just going to be running into the 00:13:04.409 --> 00:13:08.629 attack if they sneeze right so. It doesn't take 00:13:08.629 --> 00:13:11.429 much for them to get thrown into the attack if 00:13:11.429 --> 00:13:14.509 they have that much potassium so you're going 00:13:14.509 --> 00:13:18.299 to be looking at like insulin. with dextrose 00:13:18.299 --> 00:13:21.159 your di and then you're going to be looking at 00:13:21.159 --> 00:13:24.820 calcium um especially in high potassium you're 00:13:24.820 --> 00:13:28.000 going to be giving calcium and gluconate um the 00:13:28.000 --> 00:13:30.700 way i describe it to my patients who have high 00:13:30.700 --> 00:13:34.059 potassium is that calcium is going to go in and 00:13:34.059 --> 00:13:36.480 kind of hug the heart you know because the heart's 00:13:36.480 --> 00:13:38.580 kind of having like this anxiety attack right 00:13:38.580 --> 00:13:41.779 now so calcium will go in and kind of give the 00:13:41.779 --> 00:13:45.730 heart a hug and keep it stable and keep it from 00:13:45.730 --> 00:13:48.190 throwing itself into this wonky ass arrhythmia, 00:13:48.350 --> 00:13:51.570 right? So it goes in and it hugs the heart. And 00:13:51.570 --> 00:13:56.370 then you have, you have KXL8, right? So you can 00:13:56.370 --> 00:14:00.590 shit it out. And then a new one is going to be 00:14:00.590 --> 00:14:04.049 Albuterol. So there you give a lot of Albuterol, 00:14:04.210 --> 00:14:06.730 which also helps the shift. So it's called a 00:14:06.730 --> 00:14:10.629 shifting protocol in the ER. We call it a shifting 00:14:10.629 --> 00:14:13.840 protocol. So you're looking at D50. Might give 00:14:13.840 --> 00:14:16.519 an amp or two a d50 and it started insulin drip 00:14:16.519 --> 00:14:20.220 to get the potassium back into the cells And 00:14:20.220 --> 00:14:22.460 then you're going to be giving calcium gluconate. 00:14:22.460 --> 00:14:25.379 You're going to be giving KX light or low calma 00:14:25.379 --> 00:14:28.940 whichever one that you have on hand and then 00:14:28.940 --> 00:14:31.299 If they're really really bad off, they might 00:14:31.299 --> 00:14:35.159 get hemodialysis emergent dialysis to pull that 00:14:35.159 --> 00:14:39.080 extra potassium out And then you have your arrhythmias 00:14:39.080 --> 00:14:42.059 with calcium and stuff like that. Okay. But the 00:14:42.059 --> 00:14:45.080 big ones are going to be like potassium. And 00:14:45.080 --> 00:14:49.360 we went over VTAC, VFib. We went over the bundle 00:14:49.360 --> 00:14:52.039 branch blocks. And then we went over your heart 00:14:52.039 --> 00:14:56.100 blocks. And then we went over your atrial dysrhythmias 00:14:56.100 --> 00:14:58.940 with Aflutter and Afib and then your Afib with 00:14:58.940 --> 00:15:03.139 RVR and Afib or Aflutter with RVR, which is something 00:15:03.139 --> 00:15:06.200 new to me. So outside of that, man, I think that's 00:15:06.200 --> 00:15:09.159 it. All right. This is going to be the episode 00:15:09.159 --> 00:15:11.139 over dysrhythmias. I just wanted to make sure 00:15:11.139 --> 00:15:13.679 that we covered those because I don't know what 00:15:13.679 --> 00:15:15.500 they're going to touch on in this episode, but 00:15:15.500 --> 00:15:18.379 I want to make sure that especially for the heart 00:15:18.379 --> 00:15:20.919 blocks that you guys don't get tripped up with 00:15:20.919 --> 00:15:23.879 the heart blocks again. Broken record. You're 00:15:23.879 --> 00:15:26.919 looking at your fucking P wave. All right. Your 00:15:26.919 --> 00:15:29.240 P wave will determine what type of heart block 00:15:29.240 --> 00:15:32.740 you are in. If your P wave is sitting a little 00:15:32.740 --> 00:15:36.480 bit further from the QRS complex. You're in a 00:15:36.480 --> 00:15:38.480 you're in a hard block type. You're in a hard 00:15:38.480 --> 00:15:42.700 block one first degree hard block. And then if 00:15:42.700 --> 00:15:46.899 your P wave starts marching away from your QRS 00:15:46.899 --> 00:15:49.320 complex and then you get a drop beat, that's 00:15:49.320 --> 00:15:52.659 going to be a Winky Bot or Mobitz type one second 00:15:52.659 --> 00:15:57.320 degree hard block Mobitz type one. And then if 00:15:57.320 --> 00:16:01.639 your key if your P wave is stationary. a then 00:16:01.639 --> 00:16:04.320 you get a random drop beat that's going to be 00:16:04.320 --> 00:16:10.159 a second degree heart block mobits type two and 00:16:10.159 --> 00:16:12.700 then if your P wave is just all over the damn 00:16:12.700 --> 00:16:15.720 place you know your atria are just contracting 00:16:15.720 --> 00:16:19.080 whatever the fuck they feel like it then you're 00:16:19.080 --> 00:16:22.240 going to be in a third degree heart block okay 00:16:22.240 --> 00:16:25.259 so again your heart blocks are going to be determined 00:16:25.259 --> 00:16:30.210 by the P wave This is coming from nursing school. 00:16:30.289 --> 00:16:32.769 This is not a cardiologist telling you this, 00:16:32.769 --> 00:16:37.330 but for your intensive testing purposes. Okay. 00:16:37.850 --> 00:16:40.490 Your heart blocks are going to be determined 00:16:40.490 --> 00:16:45.090 by your P wave. Now, if you want to be a cardiologist 00:16:45.090 --> 00:16:47.769 and you want to say, well, your V1 and your V2 00:16:47.769 --> 00:16:50.710 and your AVR, you know, leads need to look like 00:16:50.710 --> 00:16:53.169 this and all that. Well, then you do that, man. 00:16:53.559 --> 00:16:58.879 But in the ER and for nursing on our end when 00:16:58.879 --> 00:17:01.899 just looking at the shit your P wave determines 00:17:01.899 --> 00:17:05.400 what type of heart block you have All right, 00:17:05.680 --> 00:17:09.519 and then yeah, that's it. All right guys Enjoy 00:17:09.519 --> 00:17:12.200 the episode. Okay, I'm back like a bad habit. 00:17:12.680 --> 00:17:16.519 Um, I want to go over PVC's and then by Jiminy 00:17:16.519 --> 00:17:21.950 and try Jiminy Again, I do not know what arrhythmias 00:17:21.950 --> 00:17:25.430 this episode will go over because I haven't listened 00:17:25.430 --> 00:17:31.309 to it yet. But your PVCs are your preventricular 00:17:31.309 --> 00:17:35.269 contractions. So you will have like a normal 00:17:35.269 --> 00:17:39.630 QRS complex. Right. And then just out of nowhere, 00:17:39.630 --> 00:17:45.210 you'll get this really bizarre looking kind of 00:17:45.210 --> 00:17:49.829 beat looking thing. And it's just where the ventricles 00:17:49.829 --> 00:17:54.990 just kind of contracted a little too early. So 00:17:54.990 --> 00:17:58.890 what I've come to learn is the ventricles are 00:17:58.890 --> 00:18:02.750 extremely sensitive. And so if the ventricles 00:18:02.750 --> 00:18:05.269 start reading that they're not getting enough 00:18:05.269 --> 00:18:07.910 oxygen, then they'll start to freak out and then 00:18:07.910 --> 00:18:10.509 they'll start throwing PVCs like all over the 00:18:10.509 --> 00:18:14.299 damn place, right? So for a good chunk, I'm not 00:18:14.299 --> 00:18:17.980 going to give a percentage, but I will say if 00:18:17.980 --> 00:18:22.599 your patient doesn't have a cardiac history and 00:18:22.599 --> 00:18:25.200 you're in the ER, wherever the hell you're at, 00:18:25.240 --> 00:18:29.059 if they don't have a cardiac history, then if 00:18:29.059 --> 00:18:32.519 you see PVCs, they're probably just sitting in 00:18:32.519 --> 00:18:35.200 a weird position and you might want to just set 00:18:35.200 --> 00:18:38.319 them up, pull them up, put some oxygen on them, 00:18:38.619 --> 00:18:42.309 something. to get them to get oxygenated, even 00:18:42.309 --> 00:18:44.690 though their pulse ox is probably reading 90 00:18:44.690 --> 00:18:47.269 or something like that. Just slap some O2 on 00:18:47.269 --> 00:18:50.150 them at two liters and then see if that kind 00:18:50.150 --> 00:18:53.289 of resolves their weird looking PVCs. Because 00:18:53.289 --> 00:18:56.410 again, the ventricles are extremely sensitive. 00:18:57.269 --> 00:19:01.809 We had a patient that had a shot that the I guess 00:19:01.809 --> 00:19:04.950 the terminating portion of it dipped a little 00:19:04.950 --> 00:19:08.369 too low into the heart. And I guess it started 00:19:08.670 --> 00:19:12.690 You know, rubbing the ventricles as it was contracting. 00:19:13.130 --> 00:19:15.670 And so they would throw a little weird PVC is 00:19:15.670 --> 00:19:18.309 whenever she would sit in like a weird position. 00:19:18.990 --> 00:19:21.450 And she said it was normal and she can feel it. 00:19:21.450 --> 00:19:23.809 So she sits in certain positions that way. It 00:19:23.809 --> 00:19:27.170 doesn't do that. But we'll go into by Jiminy. 00:19:28.089 --> 00:19:30.289 And let me check before I give you guys wrong 00:19:30.289 --> 00:19:37.069 information. OK. So by Jiminy will be a normal 00:19:37.069 --> 00:19:41.539 QRS. complex and then you'll have a P you have 00:19:41.539 --> 00:19:45.539 a PVC and it'll be one for one so you'll have 00:19:45.539 --> 00:19:47.759 a QRS and then you have a PVC then you have a 00:19:47.759 --> 00:19:50.460 QRS then you have a PVC you have a QRS and then 00:19:50.460 --> 00:19:52.359 you have a PVC there right there is going to 00:19:52.359 --> 00:19:56.700 be by Jiminy okay and then you have try Jiminy 00:19:56.700 --> 00:19:59.579 which is a two for one special so you'll get 00:19:59.579 --> 00:20:04.099 two QRS complexes and then you'll get one PVC 00:20:04.099 --> 00:20:12.200 so QRS QRS PVC QRS, QRS, PVC, QRS, QRS, PVC. 00:20:12.960 --> 00:20:18.380 That will be trigeminy. Okay, so you'll just 00:20:18.380 --> 00:20:22.259 have your normal PVCs. And then you will have 00:20:22.259 --> 00:20:25.700 your by Jiminy, which will be one for one. So 00:20:25.700 --> 00:20:29.579 QRS, PVC, and then you'll have your trigeminy, 00:20:29.599 --> 00:20:34.250 which will be QRS, QRS, PVC, so a two -for -one 00:20:34.250 --> 00:20:37.450 special with trigeminy. So basically, every second 00:20:37.450 --> 00:20:41.289 beat will be bygiminy, and then every third beat 00:20:41.289 --> 00:20:46.230 will be trigeminy, okay? And now I think I am 00:20:46.230 --> 00:20:49.029 done. You know, usually when we talk about a 00:20:49.029 --> 00:20:51.609 medical diagnosis, there's this expectation of 00:20:51.609 --> 00:20:54.509 absolute precision, almost like structural engineering, 00:20:54.609 --> 00:20:56.920 I guess. Right, exactly. Like the structure has 00:20:56.920 --> 00:20:59.619 failed. Yeah. Like you break your femur, the 00:20:59.619 --> 00:21:02.279 x -ray shows a jagged white line right through 00:21:02.279 --> 00:21:04.960 the bone, and the orthopedic surgeon just points 00:21:04.960 --> 00:21:07.960 at the screen and says, well, there it is, broken. 00:21:08.079 --> 00:21:11.359 It's incredibly binary. It's clean, it's visible, 00:21:11.759 --> 00:21:13.759 and the intervention is just purely mechanical. 00:21:13.960 --> 00:21:17.019 But then you step into the intensive care unit, 00:21:17.259 --> 00:21:19.180 you look at a failing heart, and suddenly that 00:21:19.180 --> 00:21:22.099 structural mechanical mindset -like relying on 00:21:22.099 --> 00:21:25.160 an x -ray machine, it feels completely inadequate. 00:21:25.339 --> 00:21:27.140 Oh, it really does. Because we usually think 00:21:27.140 --> 00:21:29.180 of the cardiovascular system as plumbing, right? 00:21:29.220 --> 00:21:31.619 Yeah. You have clogged pipes, blocked coronary 00:21:31.619 --> 00:21:34.299 arteries, physical fluid overload. Right, the 00:21:34.299 --> 00:21:36.400 plumbing. But the reality of the ICU is that 00:21:36.400 --> 00:21:38.940 the heart is actually a house with a really complex, 00:21:39.140 --> 00:21:43.259 highly sensitive electrical grid. And when that 00:21:43.240 --> 00:21:45.500 grid shorts out, the plumbing doesn't matter 00:21:45.500 --> 00:21:48.680 at all. The pump just stops. It is the absolute 00:21:48.680 --> 00:21:52.059 definition of a critical failure. I mean, if 00:21:52.059 --> 00:21:54.740 the electricity fails, the pump dies. Period. 00:21:55.099 --> 00:21:57.559 Wow. And to save a life in that exact moment, 00:21:57.819 --> 00:21:59.799 you have to completely shift your paradigm. You 00:21:59.799 --> 00:22:02.720 have to stop thinking like a plumber and start 00:22:02.720 --> 00:22:04.980 thinking like a master electrician. You have 00:22:04.980 --> 00:22:07.539 to read the invisible currents traveling through 00:22:07.539 --> 00:22:09.839 the myocardium. Which is wild to think about. 00:22:10.259 --> 00:22:12.769 So welcome to this deep dive. The mission today 00:22:12.769 --> 00:22:15.650 is clear, and honestly, it's intense. Totally 00:22:15.650 --> 00:22:18.210 intense. We are taking the source material provided, 00:22:18.269 --> 00:22:20.490 which is this massive stack of critical care 00:22:20.490 --> 00:22:22.750 literature, and we are going to try and transform 00:22:22.750 --> 00:22:26.430 you, the listener, into an elite ICU intensivist 00:22:26.430 --> 00:22:28.890 and critical care nursing instructor. That's 00:22:28.890 --> 00:22:31.190 the goal. We're looking exclusively at the electrical 00:22:31.190 --> 00:22:34.150 grid of the heart, the electrocardiographic monitoring, 00:22:34.589 --> 00:22:37.670 the cellular pathophysiology, and, well, the 00:22:37.670 --> 00:22:39.849 lethal dysrhythmias that occur when this whole 00:22:39.849 --> 00:22:42.400 system breaks down. And just to be clear, assuming 00:22:42.400 --> 00:22:44.720 you already know the basics like, we aren't going 00:22:44.720 --> 00:22:47.640 to waste time defining what a P -Wave or QRS 00:22:47.640 --> 00:22:49.559 complex is. We are diving straight into the deep 00:22:49.559 --> 00:22:51.880 end today. Straight into it. I want to establish 00:22:51.880 --> 00:22:53.960 our methodology upfront, too. We're doing this 00:22:53.960 --> 00:22:56.059 by aggressively applying the Pareto principle. 00:22:56.220 --> 00:22:58.799 Yes, the 80 -20 rule. Exactly. We are stripping 00:22:58.799 --> 00:23:01.839 away the academic fluff and focusing on the exact, 00:23:02.200 --> 00:23:04.980 precise information that dictates your clinical 00:23:04.980 --> 00:23:08.059 understanding, your exam performance, and most 00:23:08.059 --> 00:23:11.019 importantly, bedside decision -making when a 00:23:11.019 --> 00:23:13.819 patient is actively dying in front of you. And 00:23:13.819 --> 00:23:16.599 we are not just memorizing squiggles on a monitor 00:23:16.599 --> 00:23:21.019 today. We are using what sources call Which I 00:23:21.019 --> 00:23:23.599 love. Tell us about that. It's this vital cognitive 00:23:23.599 --> 00:23:26.269 framework. You don't just look at an ECG and 00:23:26.269 --> 00:23:29.190 shout out the name of a rhythm. That's what a 00:23:29.190 --> 00:23:31.990 novice does. An intensivist approaches every 00:23:31.990 --> 00:23:34.710 single rhythm as a cascading sequence. So you 00:23:34.710 --> 00:23:37.109 ask, what is the underlying problem? How does 00:23:37.109 --> 00:23:39.509 that lead to failing physiology at a cellular 00:23:39.509 --> 00:23:42.009 and hemodynamic level? OK, problem physiology. 00:23:42.049 --> 00:23:44.250 Then what is the immediate threat to the patient's 00:23:44.250 --> 00:23:46.930 life? What is the specific intervention required? 00:23:47.250 --> 00:23:49.690 And finally, how do we reassess to prove our 00:23:49.690 --> 00:23:52.210 intervention actually worked? Problem, failing 00:23:52.210 --> 00:23:56.250 physiology, immediate threat, intervention, reassessment. 00:23:56.410 --> 00:23:58.829 I love how systematic that is. So let's ground 00:23:58.829 --> 00:24:01.490 this in our house analogy. You have the plumbing, 00:24:01.730 --> 00:24:03.990 which is the physical blood flow, and the electricity, 00:24:04.069 --> 00:24:06.150 which is the conduction system. Today, we are 00:24:06.150 --> 00:24:08.670 the electricians. I like that. We are tracking 00:24:08.670 --> 00:24:11.190 the spark from the SA node, which is basically 00:24:11.190 --> 00:24:14.309 the main... breaker panel of the house, down 00:24:14.309 --> 00:24:17.049 to the AV node, which acts as a relay box, and 00:24:17.049 --> 00:24:19.470 then down the bundle of his and Purkinje fibers, 00:24:19.569 --> 00:24:21.849 which is the actual wiring buried in the walls 00:24:21.849 --> 00:24:24.289 of the ventricles. That is a perfect visualization. 00:24:25.190 --> 00:24:27.410 And before we get into the systemic failures, 00:24:27.589 --> 00:24:29.769 let's briefly establish the absolute essential 00:24:29.769 --> 00:24:32.589 rule of this grid, which is that time is tissue. 00:24:32.829 --> 00:24:35.269 Time is tissue. Right. When you look at an ECG 00:24:35.269 --> 00:24:37.369 strip, the horizontal axis isn't just distance. 00:24:37.490 --> 00:24:40.559 It is a strict measurement of time. One small 00:24:40.559 --> 00:24:44.900 square equals exactly .04 seconds. One large 00:24:44.900 --> 00:24:48.200 square is .20 seconds. OK. If a signal takes 00:24:48.200 --> 00:24:50.200 too long to get from the breaker panel to the 00:24:50.200 --> 00:24:52.619 wiring in the walls, the tissue starves. So we 00:24:52.619 --> 00:24:55.380 are hunting for delays, blockages, and rogue 00:24:55.380 --> 00:24:58.000 surges of electricity. Let's start with the most 00:24:58.000 --> 00:25:00.480 common clinical headache that absolutely fills 00:25:00.480 --> 00:25:04.579 up ICU beds across the world. The atrial chaos. 00:25:04.940 --> 00:25:07.440 Atrial fibrillation and atrial flutter. Exactly. 00:25:07.480 --> 00:25:09.539 Let's get the 80 -20 overview on this. So this 00:25:09.539 --> 00:25:11.960 is a massive drain on health care resources and 00:25:11.960 --> 00:25:14.880 a major cause of morbidity. The 80 -20 overview 00:25:14.880 --> 00:25:18.039 here is that atrial fibrillation, or AFib, is 00:25:18.039 --> 00:25:20.559 total electrical disorganization in the top chambers 00:25:20.559 --> 00:25:22.700 of the heart. The atria. Right. You have multiple 00:25:22.700 --> 00:25:26.279 ectopic foci. These are basically rogue electrical 00:25:26.279 --> 00:25:28.599 cells firing rapidly and completely out of sync. 00:25:28.819 --> 00:25:31.059 And how is flutter different? Atrial flutter 00:25:31.059 --> 00:25:33.819 is similar, but instead of total chaos, it's 00:25:33.819 --> 00:25:36.559 usually a single rogue focus firing in a rapid 00:25:36.559 --> 00:25:39.480 macro reentrant circuit. It causes a very distinct 00:25:39.480 --> 00:25:41.759 sawtooth pattern on the monitor. Okay, let's 00:25:41.759 --> 00:25:44.039 get into the pathophysiology. How do we get from 00:25:44.039 --> 00:25:47.099 a normal, organized heartbeat to a state where 00:25:47.099 --> 00:25:49.339 rogue cells are just firing off like fireworks? 00:25:49.640 --> 00:25:51.619 What's the actual trigger? It almost always starts 00:25:51.619 --> 00:25:54.559 with structural stretch or ischemic damage. Think 00:25:54.559 --> 00:25:56.839 about a patient with chronic hypertension or 00:25:56.839 --> 00:25:59.660 heart failure or valvular disease. The plumbing 00:25:59.660 --> 00:26:02.339 problems. Exactly. The physical tissue of the 00:26:02.339 --> 00:26:04.619 atria gets stretched out over years or gets scarred 00:26:04.619 --> 00:26:08.240 from sheer physical stress. This structural change 00:26:08.240 --> 00:26:11.079 actually alters the ion channels at the cellular 00:26:11.079 --> 00:26:13.680 level. Wait, so stretching the muscle physically 00:26:13.680 --> 00:26:16.920 changes its electrical properties? Yes. The resting 00:26:16.920 --> 00:26:19.380 membrane potential of these atrial cells changes, 00:26:19.680 --> 00:26:22.339 making them incredibly irritable. They stop waiting 00:26:22.339 --> 00:26:24.980 for the main breaker panel, the SA node, to tell 00:26:24.980 --> 00:26:27.000 them what to do. They just start firing on their 00:26:27.000 --> 00:26:29.490 own. So the physiologic change is that instead 00:26:29.490 --> 00:26:32.450 of a coordinated smooth squeeze, the atria are 00:26:32.450 --> 00:26:35.589 just quivering like a bag of worms. It's exactly 00:26:35.589 --> 00:26:37.849 like a bag of worms. The electrical impulses 00:26:37.849 --> 00:26:40.650 are firing at something like 350 to 600 times 00:26:40.650 --> 00:26:43.670 a minute in AFib. Wow, and a quiver is definitely 00:26:43.670 --> 00:26:46.289 not a squeeze. It's terribly inefficient. But 00:26:46.289 --> 00:26:48.490 the body has a defense mechanism, right? It does. 00:26:48.710 --> 00:26:52.130 The AV nodar relay box between the top and bottom 00:26:52.130 --> 00:26:54.829 of the heart acts like a bouncer at a nightclub. 00:26:55.089 --> 00:26:57.569 OK, a bouncer. Yeah, it has an inherent refractory 00:26:57.569 --> 00:27:00.069 period, meaning it simply cannot process 600 00:27:00.069 --> 00:27:02.809 signals a minute. It physically blocks most of 00:27:02.809 --> 00:27:04.950 that chaotic electricity from reaching the ventricles. 00:27:05.230 --> 00:27:08.150 But the bouncer can only do so much. Eventually, 00:27:08.369 --> 00:27:10.869 the AV node gets overwhelmed and too many signals 00:27:10.869 --> 00:27:13.130 slip through. Right, and when too many signals 00:27:13.130 --> 00:27:16.089 slip through, the ventricular rate, the actual 00:27:16.089 --> 00:27:19.049 main pumping chambers, jumps to over 100 beats 00:27:19.049 --> 00:27:22.549 per minute, sometimes up to 150 or 170. And that 00:27:22.549 --> 00:27:24.930 leads to decompensation. Immediate decompensation. 00:27:24.930 --> 00:27:27.450 Because the atria are just quivering, you lose 00:27:27.450 --> 00:27:29.509 what we call the atrial kick. The atrial kick, 00:27:29.509 --> 00:27:31.869 that's the final active squeeze of blood from 00:27:31.869 --> 00:27:34.349 the atria into the ventricles right before the 00:27:34.349 --> 00:27:37.569 ventricles contract, right? Yes. total cardiac 00:27:37.569 --> 00:27:40.730 output relies on that little kick. It's massive. 00:27:41.390 --> 00:27:43.970 In a healthy person, the atrial kick provides 00:27:43.970 --> 00:27:46.049 about 20 to 30 percent of ventricular filling 00:27:46.049 --> 00:27:48.869 the preload. Oh, wow. So if you lose the atrial 00:27:48.869 --> 00:27:51.230 kick because the atria is just vibrating, you 00:27:51.230 --> 00:27:53.430 instantly lose 20 to 30 percent of your cardiac 00:27:53.430 --> 00:27:56.769 output. Just gone. Just gone. The clinical findings 00:27:56.769 --> 00:27:59.190 that result are immediate. The patient feels 00:27:59.190 --> 00:28:01.470 dizzy, their blood pressure drops, they might 00:28:01.470 --> 00:28:03.509 feel palpitations or shortness of breath. So 00:28:03.509 --> 00:28:06.299 if I'm at the bedside, assessing this patient, 00:28:06.779 --> 00:28:09.240 what am I looking for early on, and what is the 00:28:09.240 --> 00:28:11.539 dangerous finding that requires immediate action? 00:28:11.839 --> 00:28:14.099 Early on, they might just complain of fatigue 00:28:14.099 --> 00:28:17.319 or palpitations. Yeah. But the classic assessment 00:28:17.319 --> 00:28:19.940 finding, the one you will physically feel when 00:28:19.940 --> 00:28:23.440 you check their radial pulse, is a rhythm that 00:28:23.440 --> 00:28:27.220 is irregularly irregular. Irregularly, irregular, 00:28:27.299 --> 00:28:29.319 meaning there's no pattern at all. There is no 00:28:29.319 --> 00:28:32.019 pattern whatsoever. It's completely chaotic because 00:28:32.019 --> 00:28:34.559 the AV node is just letting those signals through 00:28:34.559 --> 00:28:37.059 at random intervals. Got it. And the dangerous 00:28:37.059 --> 00:28:39.559 phase? The dangerous phase is what we call rapid 00:28:39.559 --> 00:28:42.319 ventricular response, or RVR. This is when the 00:28:42.319 --> 00:28:44.619 bouncer at the AV node completely fails and the 00:28:44.619 --> 00:28:47.440 ventricles start beating at, say, 160 times a 00:28:47.440 --> 00:28:49.119 minute. Which doesn't leave enough time for the 00:28:49.119 --> 00:28:51.470 heart to fill up with blood. Exactly. At that 00:28:51.470 --> 00:28:53.509 speed, the heart simply does not have time to 00:28:53.509 --> 00:28:55.650 fill with blood during diastole. If the plump 00:28:55.650 --> 00:28:57.430 is empty, it doesn't matter how fast it's beating. 00:28:57.869 --> 00:29:00.789 Cardiac output plummets. So you'd see profound 00:29:00.789 --> 00:29:04.410 hypotension. Hypotension, cold and clammy skin 00:29:04.410 --> 00:29:08.009 as peripheral perfusion drops, and a decreased 00:29:08.009 --> 00:29:10.529 level of consciousness because the brain is starving 00:29:10.529 --> 00:29:12.990 for oxygen. Well, let's talk diagnostics. Obviously, 00:29:13.109 --> 00:29:16.250 the ECG is our primary tool here. What does this 00:29:16.250 --> 00:29:19.349 chaos look like on the grid? On the ECG, AFIP 00:29:19.349 --> 00:29:22.690 shows a chaotic, squiggly baseline. There are 00:29:22.690 --> 00:29:24.890 absolutely no merriable P waves because there 00:29:24.890 --> 00:29:27.730 is no uniform atrial depolarization. Just noise. 00:29:27.849 --> 00:29:30.609 Just noise. But the QRS complex, the ventricular 00:29:30.609 --> 00:29:32.950 beat, is usually perfectly narrow and normal, 00:29:33.029 --> 00:29:34.710 which is completely irregular in its timing. 00:29:34.930 --> 00:29:37.369 And for flutter? For atrial flutter, the bouncer 00:29:37.369 --> 00:29:40.089 at the AV node is a bit more organized. You'll 00:29:40.089 --> 00:29:42.630 see very distinct F waves, a sawtooth pattern, 00:29:43.069 --> 00:29:44.970 often in a mathematical ratio like 2 to 1 or 00:29:44.970 --> 00:29:48.009 3 to 1 with the QRS complexes. Yeah. But in both 00:29:48.009 --> 00:29:50.130 cases, your PR interval is completely unmeasurable. 00:29:50.269 --> 00:29:52.549 OK, so let's run the ADPIU on this. I'm an ICU 00:29:52.549 --> 00:29:54.430 nurse. I walk into the room, and the monitor 00:29:54.430 --> 00:29:57.289 is showing this irregular chaos. The patient's 00:29:57.289 --> 00:30:00.180 heart rate is 100. What is my immediate priority? 00:30:00.380 --> 00:30:02.099 Like, what am I doing first, next, and then? 00:30:02.500 --> 00:30:04.880 Your absolute first priority is assessing the 00:30:04.880 --> 00:30:07.779 patient's hemodynamic stability. Treat the patient, 00:30:08.079 --> 00:30:10.339 not the monitor. Are they maintaining their blood 00:30:10.339 --> 00:30:13.539 pressure? Are they alert and oriented? Or are 00:30:13.539 --> 00:30:17.140 they pale, diaphoretic, and hypotensive? So the 00:30:17.140 --> 00:30:18.980 highest priority nursing diagnoses here would 00:30:18.980 --> 00:30:21.680 be risk for decreased cardiac output and risk 00:30:21.680 --> 00:30:24.259 for impaired tissue perfusion. Spot on. Let's 00:30:24.259 --> 00:30:26.720 say their blood pressure is okay for now, but 00:30:26.720 --> 00:30:29.180 the heart rate is still 140. What's the intervention? 00:30:29.799 --> 00:30:33.099 Next T and then. Our measurable goal for planning 00:30:33.099 --> 00:30:35.599 is to drop that heart rate below 100 beats per 00:30:35.599 --> 00:30:38.460 minute. We do this primarily through rate -controlling 00:30:38.460 --> 00:30:41.339 medications. The big guns here are calcium channel 00:30:41.339 --> 00:30:44.680 blockers, specifically Diltiasm, or beta blockers 00:30:44.680 --> 00:30:46.740 like Metaprolol. I really want to dig into the 00:30:46.740 --> 00:30:49.299 pharmacology here. Why those specific drugs? 00:30:49.420 --> 00:30:51.880 How do they actually work to fix this? They target 00:30:51.880 --> 00:30:53.859 the AV node. Remember the AV node is the bouncer. 00:30:54.039 --> 00:30:56.880 Diltiazem blocks the influx of calcium ions into 00:30:56.880 --> 00:30:59.579 the pacemaker cells of the AV node during phase 00:30:59.579 --> 00:31:02.559 zero of the action potential. This literally 00:31:02.559 --> 00:31:04.720 slows down the electrical conduction through 00:31:04.720 --> 00:31:06.720 the node. It makes the balancer stronger and 00:31:06.720 --> 00:31:09.619 slower. Makes sense. And metaprolol? Metaprolol 00:31:09.619 --> 00:31:12.460 does something similar, but through beta -1 adrenergic 00:31:12.460 --> 00:31:15.339 blockade, blunting the sympathetic nervous system's 00:31:15.339 --> 00:31:17.839 effect on the heart. By slowing the conduction 00:31:17.839 --> 00:31:20.700 through the AV node, fewer chaotic signals reach 00:31:20.700 --> 00:31:23.000 the ventricles, the heart rate drops, filling 00:31:23.000 --> 00:31:25.599 time increases, and cardiac output improves. 00:31:26.000 --> 00:31:27.980 What about amiodarone? Because I see that used 00:31:27.980 --> 00:31:31.920 a lot in the ICU. Amiodarone is a potent class 00:31:31.920 --> 00:31:34.619 3 anti -arrhythmic. Instead of just slowing the 00:31:34.619 --> 00:31:36.839 heart rate, it actually attempts to convert the 00:31:36.839 --> 00:31:38.880 chaotic rhythm back to a normal sinus rhythm. 00:31:38.970 --> 00:31:41.809 Oh, so it's a rhythm controller, not just rate. 00:31:41.990 --> 00:31:44.309 Right. It works primarily by blocking potassium 00:31:44.309 --> 00:31:47.089 channels, which prolongs the repolarization phase, 00:31:47.109 --> 00:31:49.410 the reset period of the cardiac action potential. 00:31:49.990 --> 00:31:51.890 It forces the chaotic cells to take a longer 00:31:51.890 --> 00:31:54.450 pause, hoping the SA node will step back in and 00:31:54.450 --> 00:31:56.710 take over. OK, so we're giving Diltiazem to slow 00:31:56.710 --> 00:31:59.150 the rate. But the other major medication class 00:31:59.150 --> 00:32:01.710 we have to talk about with AFib is anticoagulants, 00:32:01.990 --> 00:32:04.029 things like heparin drips in the acute phase 00:32:04.029 --> 00:32:06.829 or epixaban and warfarin long term. Very important. 00:32:07.150 --> 00:32:09.970 But wait, I'm looking at the critically, if the 00:32:09.970 --> 00:32:12.890 primary problem is an electrical failure, why 00:32:12.890 --> 00:32:15.650 are we giving medication that alters the hematological 00:32:15.650 --> 00:32:17.509 system? Like, why are we thinning the blood? 00:32:17.990 --> 00:32:19.349 That is the most important critical thinking 00:32:19.349 --> 00:32:21.710 question you can ask, and it's a massive safety 00:32:21.710 --> 00:32:24.549 concept. Because the atria are quivering and 00:32:24.549 --> 00:32:27.269 not actively squeezing, the blood inside them 00:32:27.269 --> 00:32:29.589 becomes stagnant. Oh, right. It just pools in 00:32:29.589 --> 00:32:32.329 the corners, specifically in a small pouch called 00:32:32.329 --> 00:32:35.269 the left atrial appendage. And stagnant blood 00:32:35.269 --> 00:32:39.259 coagulates. Exactly. Vertaus triad tells us that 00:32:39.259 --> 00:32:42.900 stasis of blood flow leads to thrombosis. A clot 00:32:42.900 --> 00:32:45.900 forms in that appendage. Now imagine we give 00:32:45.900 --> 00:32:48.619 amiodarone or we use electricity to shock the 00:32:48.619 --> 00:32:51.099 heart back into a normal rhythm. The atria suddenly 00:32:51.099 --> 00:32:53.759 snapped back into a strong forceful contraction. 00:32:53.779 --> 00:32:55.940 Yep. And it's going to squeeze that clot right 00:32:55.940 --> 00:32:58.140 out of the appendage. Right out of the left atrium. 00:32:58.319 --> 00:33:01.039 into the left ventricle, up the aorta, up the 00:33:01.039 --> 00:33:02.660 carotid arteries, and straight into the brain. 00:33:03.039 --> 00:33:05.539 You will cause a massive ischemic stroke. That 00:33:05.539 --> 00:33:08.160 is terrifying. The electrical problem creates 00:33:08.160 --> 00:33:11.059 a mechanical flow problem, which creates a hematological 00:33:11.059 --> 00:33:13.740 clotting problem, which ultimately results in 00:33:13.740 --> 00:33:16.579 a catastrophic neurological problem. It really 00:33:16.579 --> 00:33:18.119 proves why you can't just look at the heart in 00:33:18.119 --> 00:33:20.769 isolation. Which is exactly why If a patient 00:33:20.769 --> 00:33:24.410 has been an AFib for longer than 48 hours, or 00:33:24.410 --> 00:33:26.170 honestly, if we don't know exactly when it started, 00:33:26.630 --> 00:33:29.589 we absolutely cannot cardiovert them. We cannot 00:33:29.589 --> 00:33:32.529 shock them back into a normal rhythm unless we 00:33:32.529 --> 00:33:35.529 aggressively anticoagulate them first, or we 00:33:35.529 --> 00:33:38.410 perform a procedure called a transesophageal 00:33:38.410 --> 00:33:41.710 echocardiogram, a T. Let's explain the T procedure. 00:33:41.809 --> 00:33:43.650 Why not just do a regular ultrasound on their 00:33:43.650 --> 00:33:46.490 chest? A standard transthoracic echocardiogram 00:33:46.490 --> 00:33:48.869 on the outside of the chest can't see the left 00:33:48.869 --> 00:33:51.289 atrial appendage clearly because the lungs and 00:33:51.289 --> 00:33:53.769 ribs get in the way. So we sedate the patient, 00:33:54.230 --> 00:33:56.329 pass an ultrasound probe down their esophagus, 00:33:56.609 --> 00:33:58.410 and look directly at the back of the heart. Oh, 00:33:58.410 --> 00:34:00.470 that makes sense. Yeah. If we see a clot in that 00:34:00.470 --> 00:34:03.390 appendage, cardioversion is strictly contraindicated. 00:34:03.690 --> 00:34:06.750 So checking for deterioration. I know my patient's 00:34:06.750 --> 00:34:08.630 getting worse if their heart rate climbs above 00:34:08.630 --> 00:34:12.090 150, their blood pressure plummets, or they suddenly 00:34:12.090 --> 00:34:14.929 complain of chest pain. Yes. Chest pain means 00:34:14.929 --> 00:34:17.030 the rapid heart rate has outstripped the oxygen 00:34:17.030 --> 00:34:19.750 supply to the coronary arteries themselves. The 00:34:19.750 --> 00:34:22.690 myocardium is becoming ischemic. You would escalate 00:34:22.690 --> 00:34:25.090 this immediately. OK. So notifying the provider 00:34:25.090 --> 00:34:27.630 versus calling a rapid response. If they are 00:34:27.630 --> 00:34:29.929 stable but the rate is creeping up, you notify 00:34:29.929 --> 00:34:32.780 the provider. If they become hypotensive or develop 00:34:32.780 --> 00:34:35.480 chest pain, you call a rapid response or initiate 00:34:35.480 --> 00:34:38.420 your emergency protocols. Let's touch on differentials. 00:34:38.800 --> 00:34:41.699 How do I distinguish AFib from other tachycardias 00:34:41.699 --> 00:34:45.400 on the monitor, like, say, PSVT? Pattern recognition. 00:34:45.630 --> 00:34:48.769 If you see a sudden, regular, fast rhythm, say, 00:34:49.070 --> 00:34:51.409 exactly 160 beats per minute, perfectly marching 00:34:51.409 --> 00:34:54.409 out, think, ESVT, paroxysmal, supraventricular 00:34:54.409 --> 00:34:56.969 tachycardia, the key word is regular. Regular. 00:34:57.190 --> 00:34:59.889 Got it. But if it's chaotic, fast, and the QRS 00:34:59.889 --> 00:35:02.349 complexes are completely unevenly spaced, it's 00:35:02.349 --> 00:35:04.610 AFib. Let's summarize the atrial chaos using 00:35:04.610 --> 00:35:09.329 intensivist thinking. OK. Problem. A fast, irregular 00:35:09.329 --> 00:35:12.090 heart rate originating in the atria, failing 00:35:12.090 --> 00:35:15.099 physiology, loss of ventricular filling time, 00:35:15.380 --> 00:35:17.719 and the loss of the atrial kick leading to stagnant 00:35:17.719 --> 00:35:20.840 blood, immediate threat, cardiogenic shock from 00:35:20.840 --> 00:35:23.300 poor output, or an ischemic stroke from a rogue 00:35:23.300 --> 00:35:26.500 clot, intervention, rate control with calcium 00:35:26.500 --> 00:35:29.639 channel or beta blockers, and aggressive anticoagulation, 00:35:30.179 --> 00:35:32.400 and reassessment. Monitor for a heart rate under 00:35:32.400 --> 00:35:35.440 100, stable blood pressure, and intact neurological 00:35:35.440 --> 00:35:37.800 status. So if I'm distilling this down for my 00:35:37.800 --> 00:35:39.559 shift tonight, if I remember only five things, 00:35:39.800 --> 00:35:42.059 the core pathophysiology is the loss of the atrial 00:35:42.059 --> 00:35:44.579 kick. The key assessment finding is that irregularly 00:35:44.579 --> 00:35:47.079 irregular pulse. The most dangerous complication 00:35:47.079 --> 00:35:49.880 is a stroke. My priority action is assessing 00:35:49.880 --> 00:35:52.159 hemodynamic stability before I ever look at the 00:35:52.159 --> 00:35:53.920 monitor. And the definitive treatment involves 00:35:53.920 --> 00:35:56.639 rate control and anticoagulation. Perfect. The 00:35:56.639 --> 00:35:59.000 clinical picture in one sentence, an older adult 00:35:59.000 --> 00:36:01.539 with underlying heart disease presents with an 00:36:01.539 --> 00:36:04.340 irregular irregular heartbeat, dizziness and 00:36:04.340 --> 00:36:06.699 a dropping blood pressure. If you see a chaotic 00:36:06.699 --> 00:36:11.000 baseline with no P waves, think atrial fibrillation 00:36:11.000 --> 00:36:13.980 and immediately assess their hemodynamics while 00:36:13.980 --> 00:36:16.960 preparing reed control medications. OK, let's 00:36:16.960 --> 00:36:18.719 shift our focus down the conduction pathway. 00:36:19.360 --> 00:36:21.579 We just talked about the AV node acting as the 00:36:21.579 --> 00:36:23.699 bouncer, protecting the ventricles from the chaos 00:36:23.699 --> 00:36:26.519 in the atria. But what happens when the AV node 00:36:26.519 --> 00:36:28.800 goes on strike? What happens when the wiring 00:36:28.800 --> 00:36:31.239 connecting the upstairs to the downstairs is 00:36:31.239 --> 00:36:33.440 completely severed? We're talking about high 00:36:33.440 --> 00:36:35.940 -grade AV blocks. Yes. This is where things get 00:36:35.940 --> 00:36:39.019 lethal very quickly. The 80 -20 overview here 00:36:39.019 --> 00:36:42.039 focuses exclusively on the highly dangerous blocks. 00:36:42.760 --> 00:36:45.320 Second degree type 2, also known as MOBITS 2, 00:36:45.539 --> 00:36:47.480 and third degree, which is complaint heart block. 00:36:47.519 --> 00:36:49.900 OK. This is a scenario where the electrical signal 00:36:49.900 --> 00:36:52.159 from the SA node completely fails to reach the 00:36:52.159 --> 00:36:54.659 ventricles. It destroys tissue perfusion and 00:36:54.659 --> 00:36:56.760 absolutely requires external pacing to save the 00:36:56.760 --> 00:36:59.039 patient's life. Walk me through this cellular 00:36:59.039 --> 00:37:01.860 and structural pathophysiology. What actually 00:37:01.860 --> 00:37:04.320 triggers the AV node or the bundle of his to 00:37:04.320 --> 00:37:06.760 just stop conducting? The most common trigger 00:37:06.760 --> 00:37:10.630 is acute ischemia. Specifically, a myocardial 00:37:10.630 --> 00:37:12.690 infarction involving the right coronary artery, 00:37:12.829 --> 00:37:15.889 the RCA. Oh, interesting. Yeah, the RCA supplies 00:37:15.889 --> 00:37:19.190 blood directly to the AV node in about 90 % of 00:37:19.190 --> 00:37:21.710 the population. If that artery gets blocked, 00:37:22.110 --> 00:37:25.070 the AV node literally suffocates and stops conducting 00:37:25.070 --> 00:37:27.550 electricity. What else causes it? Other triggers 00:37:27.550 --> 00:37:29.789 include severe calcification of the conduction 00:37:29.789 --> 00:37:33.159 system in older adults or drug toxicity. particularly 00:37:33.159 --> 00:37:35.820 from Dagoxin or an overdose of beta blockers. 00:37:36.039 --> 00:37:38.139 So the physiologic change is that the pathway 00:37:38.139 --> 00:37:41.059 is blocked. In type 2, it's intermittently blocked. 00:37:41.619 --> 00:37:44.260 In third degree, it's completely severed. How 00:37:44.260 --> 00:37:47.179 does the body compensate for a completely severed 00:37:47.179 --> 00:37:49.440 electrical connection? The body has a desperate 00:37:49.440 --> 00:37:52.079 backup plan. The cells in the ventricles, the 00:37:52.079 --> 00:37:55.260 Purkinje fibers, have their own intrinsic automaticity. 00:37:55.579 --> 00:37:57.760 They realize that no signal is coming from above, 00:37:57.960 --> 00:37:59.980 so they try to fire on their own to keep the 00:37:59.980 --> 00:38:02.409 pump working. This is called a ventricular escape 00:38:02.409 --> 00:38:04.889 rhythm. But the wiring in the walls isn't designed 00:38:04.889 --> 00:38:08.150 to be the main breaker panel. Exactly. The phase 00:38:08.150 --> 00:38:10.570 four spontaneous depolarization of a protein 00:38:10.570 --> 00:38:13.849 shell is incredibly slow. An escape rhythm from 00:38:13.849 --> 00:38:16.090 the ventricles will only generate a heart rate 00:38:16.090 --> 00:38:18.510 of 20 to 40 beats per minute. Beating 20 times 00:38:18.510 --> 00:38:21.030 a minute? I mean, that's catastrophic. Decompensation 00:38:21.030 --> 00:38:24.010 is immediate. Cardiac output is a simple mathematical 00:38:24.010 --> 00:38:27.130 equation. Heart rate multiplied by stroke volume. 00:38:27.369 --> 00:38:30.829 If your heart rate drops from 80 to 25 instantly, 00:38:31.389 --> 00:38:33.829 your cardiac output completely collapses. So 00:38:33.829 --> 00:38:36.429 you'd see instant shock. The clinical findings 00:38:36.429 --> 00:38:39.530 reflect this sudden loss of perfusion. The patient 00:38:39.530 --> 00:38:42.269 experiences immediate syncope, crushing chest 00:38:42.269 --> 00:38:44.190 pain because the heart itself isn't getting blood, 00:38:44.809 --> 00:38:47.280 and profound cardiogenic shock. If I'm assessing 00:38:47.280 --> 00:38:49.619 this patient, what am I looking for, early versus 00:38:49.619 --> 00:38:52.079 late? Early on, they might just complain of profound, 00:38:52.260 --> 00:38:54.380 sudden fatigue or dizziness, but the classic 00:38:54.380 --> 00:38:56.739 finding is a heart rate in the 30s. And the late, 00:38:56.820 --> 00:38:59.519 dangerous findings. Complete syncope, cold and 00:38:59.519 --> 00:39:02.619 mottled skin, absent peripheral pulses, and eventually 00:39:02.619 --> 00:39:05.179 periods of apnea as the respiratory center in 00:39:05.179 --> 00:39:07.039 the brain shuts down from lack of blood flow. 00:39:07.440 --> 00:39:10.059 Let's look at the diagnostics. How do we differentiate 00:39:10.059 --> 00:39:13.030 these lethal blocks on the ECG grid? For second 00:39:13.030 --> 00:39:15.769 degree tag two, you will see a normal constant 00:39:15.769 --> 00:39:18.989 PR interval on the beats that do conduct. The 00:39:18.989 --> 00:39:21.590 signal makes it through. But then suddenly and 00:39:21.590 --> 00:39:24.449 unpredictably, there is a dropped QRS complex. 00:39:25.050 --> 00:39:27.110 You see a P wave and then absolutely nothing. 00:39:27.289 --> 00:39:29.010 The signal was blocked. And for third degree? 00:39:29.349 --> 00:39:31.750 For third degree or complete heart block, it 00:39:31.750 --> 00:39:33.969 is a total divorce between the atria and the 00:39:33.969 --> 00:39:37.170 ventricles. The SA node is firing normally, so 00:39:37.170 --> 00:39:39.369 you see P -ways marching out regularly at, say, 00:39:39.469 --> 00:39:42.449 80 beats per minute. OK. But the ventricles are 00:39:42.449 --> 00:39:44.489 firing on their slow escape rhythm at 30 beats 00:39:44.489 --> 00:39:47.590 per minute. The keyways and the QRS complexes 00:39:47.590 --> 00:39:49.650 have absolutely no relationship to each other. 00:39:49.710 --> 00:39:51.909 They're beating completely independently. So 00:39:51.909 --> 00:39:53.949 if I recognize this on the monitor and I see 00:39:53.949 --> 00:39:57.909 my patient as hypotensive and altered ADPIE time, 00:39:58.329 --> 00:40:00.840 what is my immediate priority? Your diagnosis 00:40:00.840 --> 00:40:03.579 is inadequate tissue perfusion related to extreme 00:40:03.579 --> 00:40:05.940 bradycardia. Your goal is to restore the heart 00:40:05.940 --> 00:40:08.099 rate to greater than 60 beats per minute immediately. 00:40:08.380 --> 00:40:10.480 Let's talk medications for a second because this 00:40:10.480 --> 00:40:12.840 seems straightforward. If the heart is beating 00:40:12.840 --> 00:40:16.760 at 30 beats a minute, I'm reaching for 5e atropine, 00:40:16.860 --> 00:40:19.739 right? We use atropine to speed up symptomatic 00:40:19.739 --> 00:40:23.050 bradycardia. I'll just push a milligram of atropine 00:40:23.050 --> 00:40:25.010 and speed the heart back up. I am so glad you 00:40:25.010 --> 00:40:27.150 brought that up because this is a massive exam 00:40:27.150 --> 00:40:29.710 trap and a potentially fatal real -world error. 00:40:29.929 --> 00:40:32.449 Oh, wow. OK. You must understand the pharmacology 00:40:32.449 --> 00:40:35.590 of atropine to understand why it is completely 00:40:35.590 --> 00:40:38.289 useless in a complete heart block. OK, let's 00:40:38.289 --> 00:40:40.889 unpack that. How does atropine actually work? 00:40:41.590 --> 00:40:44.510 Atropine is an anti -cholinergic drug. It works 00:40:44.510 --> 00:40:46.730 by blocking the parasympathetic vagus nerve, 00:40:46.789 --> 00:40:48.789 which normally acts like a brake on the SA and 00:40:48.789 --> 00:40:51.679 AV nodes. By removing the brake, Atropine allows 00:40:51.679 --> 00:40:54.840 the AV node to fire faster. Ah, I see the problem. 00:40:54.940 --> 00:40:57.440 Right. In a third degree block or a type 2 block 00:40:57.440 --> 00:40:59.440 occurring below the AV node in the bundle of 00:40:59.440 --> 00:41:02.179 his, the tissue is dead or physically severed. 00:41:02.280 --> 00:41:04.800 The bridge is out. So Atropine just doesn't do 00:41:04.800 --> 00:41:06.920 anything. You can give all the Atropine you want 00:41:06.920 --> 00:41:09.519 to stimulate the top of the bridge, but the signal 00:41:09.519 --> 00:41:12.639 still cannot cross the gap. Shouting at a severed 00:41:12.639 --> 00:41:14.599 wire won't make the electricity jump across. 00:41:14.960 --> 00:41:16.960 You don't need a chemical stimulant. You need 00:41:16.960 --> 00:41:19.699 raw, external electricity. That makes perfect 00:41:19.699 --> 00:41:21.820 sense when you understand the mechanism. So if 00:41:21.820 --> 00:41:23.900 atropine is out, what is the implementation? 00:41:24.239 --> 00:41:28.059 First, next, then? First, check responsiveness 00:41:28.059 --> 00:41:32.420 and blood pressure. Next T, apply the transcutaneous 00:41:32.420 --> 00:41:36.900 pacemaker pads, the TCP pads, immediately. Then 00:41:36.900 --> 00:41:39.420 you might start an infusion of epinephrine or 00:41:39.420 --> 00:41:41.559 dopamine to provide some chemical inertropic 00:41:41.559 --> 00:41:44.039 support and clamp down the blood vessels while 00:41:44.039 --> 00:41:46.579 you wait for a temporary transvenous pacer insertion. 00:41:46.730 --> 00:41:48.769 Let's walk through the physics and the procedure 00:41:48.769 --> 00:41:51.190 of transcutaneous pacing. We're literally shocking 00:41:51.190 --> 00:41:53.030 the heart through the skin, right? Yes, we are. 00:41:53.250 --> 00:41:55.550 You place one large pacing pad on the anterior 00:41:55.550 --> 00:41:58.289 chest, roughly over the V4 lead position, and 00:41:58.289 --> 00:42:00.489 the other pad on the posterior back, right between 00:42:00.489 --> 00:42:02.849 the spine and the left scapula. OK. You turn 00:42:02.849 --> 00:42:04.670 the machine to the pacing mode, set your desired 00:42:04.670 --> 00:42:07.230 rate, usually around 70 beats per minute, and 00:42:07.230 --> 00:42:09.309 then you slowly increase the electrical current, 00:42:09.449 --> 00:42:11.789 measured in milliamps. You're trying to force 00:42:11.789 --> 00:42:13.940 the electrical current. through the chest wall, 00:42:14.480 --> 00:42:17.039 through the lungs, and into the ventricular muscle 00:42:17.039 --> 00:42:20.599 to force it to depolarize. Exactly. You increase 00:42:20.599 --> 00:42:22.719 the milliamps until you achieve what we call 00:42:22.719 --> 00:42:25.260 capture. Electrical capture means that on the 00:42:25.260 --> 00:42:27.860 monitor, every single pacing spike is immediately 00:42:27.860 --> 00:42:31.699 followed by a wide QRS complex. The electricity 00:42:31.699 --> 00:42:33.960 has successfully depolarized the ventricles. 00:42:34.199 --> 00:42:37.440 But remember, the monitor can lie. Yes. You must 00:42:37.440 --> 00:42:40.550 also confirm mechanical capture. Meaning you 00:42:40.550 --> 00:42:43.150 have to feel a physical pulse that matches the 00:42:43.150 --> 00:42:46.130 pacing rate. Yes. If the machine says it's pacing 00:42:46.130 --> 00:42:49.309 at 70, but you only feel a weak pulse of 30, 00:42:49.789 --> 00:42:51.789 you do not have mechanical capture. You need 00:42:51.789 --> 00:42:54.170 to increase the current or reposition the pads. 00:42:54.489 --> 00:42:56.309 What are the complications of doing this? It 00:42:56.309 --> 00:42:58.250 sounds brutal. It is incredibly brutal. Think 00:42:58.250 --> 00:43:00.969 about it. You are blasting electrical current 00:43:00.969 --> 00:43:03.030 through the skeletal muscles of the chest wall 00:43:03.030 --> 00:43:05.739 to reach the heart. The patient's chest will 00:43:05.739 --> 00:43:08.139 visibly jump and twitch with every single heartbeat. 00:43:08.860 --> 00:43:10.980 It is agonizingly painful. So we need to sedate 00:43:10.980 --> 00:43:13.880 them. A major novice mistake is failing to advocate 00:43:13.880 --> 00:43:17.099 for the patient's pain. If the patient is conscious 00:43:17.099 --> 00:43:19.139 and their blood pressure can tolerate it, you 00:43:19.139 --> 00:43:21.940 must sedate them and provide heavy analgesia. 00:43:22.440 --> 00:43:24.840 You are torturing them to save their life, but 00:43:24.840 --> 00:43:27.199 you should minimize the torture. How do I know 00:43:27.199 --> 00:43:29.280 if this situation is escalating out of my control? 00:43:29.610 --> 00:43:33.030 the deterioration phase. The patient is deteriorating 00:43:33.030 --> 00:43:36.230 if they lose consciousness, if the pacing fails 00:43:36.230 --> 00:43:39.289 to capture despite maximum milliamps, or if they 00:43:39.289 --> 00:43:41.610 slip from profound brachcardia into complete 00:43:41.610 --> 00:43:44.469 ventricular standstill assistal. If they lose 00:43:44.469 --> 00:43:46.909 their pulse entirely, you immediately escalate 00:43:46.909 --> 00:43:50.429 from pacing to full CPR and a code blue. Let's 00:43:50.429 --> 00:43:52.449 do differentials. I know we discussed this briefly, 00:43:52.469 --> 00:43:54.670 but how do I quickly tell a type I block from 00:43:54.670 --> 00:43:57.530 a type II block? Because they both drop beats, 00:43:57.690 --> 00:43:59.889 right? Pattern recognition is key here. Type 00:43:59.889 --> 00:44:02.750 I, also known as Wenkebach, is a progressive 00:44:02.750 --> 00:44:05.570 fatigue of the AV node. You will see the PR interval 00:44:05.570 --> 00:44:08.150 getting longer and longer and longer on successive 00:44:08.150 --> 00:44:10.929 beats, and then finally, a dropped QRS. So it 00:44:10.929 --> 00:44:12.869 gives you a warning. Exactly. It's predictable. 00:44:13.030 --> 00:44:14.889 It's usually benign, and we just watch and wait. 00:44:15.369 --> 00:44:18.210 But if you see constant, identical PR intervals, 00:44:18.489 --> 00:44:20.250 and then a sudden, unpredictable, dropped beat 00:44:20.250 --> 00:44:23.070 without any warning, Think type two and prepare 00:44:23.070 --> 00:44:26.230 to pace them. That patient is teetering on the 00:44:26.230 --> 00:44:29.650 edge of complete heart block. Let's run the intensivist 00:44:29.650 --> 00:44:32.449 thinking for high -grade AV blocks. Problem. 00:44:32.849 --> 00:44:35.309 A physically severed or ischemic electrical connection 00:44:35.309 --> 00:44:37.409 between the top and bottom of the heart. Failing 00:44:37.409 --> 00:44:39.849 physiology. The ventricles are relying on an 00:44:39.849 --> 00:44:42.769 escape rhythm of 20 to 30 beats per minute. Immediate 00:44:42.769 --> 00:44:45.949 threat. Profound cardiogenic shock and biological 00:44:45.949 --> 00:44:48.880 death. Right. intervention, transcutaneous pacing 00:44:48.880 --> 00:44:51.400 to force the ventricles to bead, bypassing the 00:44:51.400 --> 00:44:54.260 broken wiring, reassessment, confirm electrical 00:44:54.260 --> 00:44:56.099 capture on the monitor and mechanical capture 00:44:56.099 --> 00:44:58.679 by checking a pulse and blood pressure. If I'm 00:44:58.679 --> 00:45:01.619 boiling this down to my five things, the core 00:45:01.619 --> 00:45:04.179 patho is a complete disconnect between the atria 00:45:04.179 --> 00:45:06.639 and the ventricles. The key assessment finding 00:45:06.639 --> 00:45:10.099 is profound bradycardia with syncope. The most 00:45:10.099 --> 00:45:12.280 dangerous complication is cardiogenic shock. 00:45:12.840 --> 00:45:15.940 My priority action is applying the TCP pads immediately. 00:45:16.349 --> 00:45:18.909 And ultimately, this patient will need a permanent, 00:45:19.250 --> 00:45:21.329 surgically -implanted pacemaker. That's it, the 00:45:21.329 --> 00:45:23.610 one -sentence clinical picture. A patient having 00:45:23.610 --> 00:45:26.269 an active right -sided myocardial infarction 00:45:26.269 --> 00:45:28.789 suddenly drops their heart rate to 30, loses 00:45:28.789 --> 00:45:31.849 consciousness, and shows absolutely no correlation 00:45:31.849 --> 00:45:34.750 between P waves and QRS complexes on the monitor. 00:45:34.849 --> 00:45:37.090 So if you see P waves marching completely independently 00:45:37.090 --> 00:45:40.010 of QRS complexes, think third -degree heart block 00:45:40.010 --> 00:45:42.550 and immediately apply a transcutaneous pacemaker. 00:45:42.710 --> 00:45:45.210 Do not waste time with atropine. Perfectly said. 00:45:45.639 --> 00:45:47.300 Okay, we've covered the heart beating too slowly. 00:45:47.619 --> 00:45:49.800 Now we need to discuss the absolute nightmare 00:45:49.800 --> 00:45:53.019 scenario in the ICU. The code blue killers. The 00:45:53.019 --> 00:45:55.099 scariest part of the job. This is when the main 00:45:55.099 --> 00:45:57.840 breaker panel shorts out and the downstream wiring 00:45:57.840 --> 00:46:00.940 just takes over at warp speed. Ventricular tachycardia 00:46:00.940 --> 00:46:03.380 and ventricular fibrillation. This is where every 00:46:03.380 --> 00:46:06.179 single second counts. Irreversible brain damage 00:46:06.179 --> 00:46:10.119 begins in minutes. The 80 -20 overview. Ventricular 00:46:10.119 --> 00:46:13.280 tachycardia, or VT, is defined as three or more 00:46:13.280 --> 00:46:15.619 premature ventricular contractions, VVCs, in 00:46:15.619 --> 00:46:18.139 a row, usually firing at a terrifying rate of 00:46:18.139 --> 00:46:21.079 150 to 250 beats per minute. And ventricular 00:46:21.079 --> 00:46:23.380 fibrillation. Ventricular fibrillation, or VF, 00:46:23.400 --> 00:46:27.079 is even worse. It is a completely chaotic, disorganized 00:46:27.079 --> 00:46:29.940 quivering of the entire ventricular muscle mass. 00:46:30.519 --> 00:46:32.940 Both of these are universally lethal without 00:46:32.940 --> 00:46:35.420 rapid intervention, and both require immediate 00:46:35.420 --> 00:46:38.099 advanced cardiovascular life support, or ACLS. 00:46:38.400 --> 00:46:41.059 Let's dive deep into the cellular pathophysiology. 00:46:41.780 --> 00:46:44.300 What actually triggers the ventricles to go rogue 00:46:44.300 --> 00:46:46.579 like this? The triggers are usually profound 00:46:46.579 --> 00:46:49.719 physiological insults. Severe ischemia, like 00:46:49.719 --> 00:46:52.679 a massive left anterior descending artery occlusion, 00:46:53.039 --> 00:46:55.320 starves the ventricular cells of oxygen, causing 00:46:55.320 --> 00:46:57.900 their resting membrane potential to destabilize. 00:46:58.219 --> 00:47:00.079 Critical electrolyte imbalances are also massive 00:47:00.079 --> 00:47:02.440 triggers. Specifically hypokalemia or hypomagnesemia, 00:47:02.599 --> 00:47:04.159 right? Low potassium and low magnesium. Yes. 00:47:04.199 --> 00:47:07.179 Let's explain why. Why does low potassium make 00:47:07.179 --> 00:47:10.059 the heart more irritable? I think a lot of people 00:47:10.059 --> 00:47:12.179 just memorize that fact without understanding 00:47:12.179 --> 00:47:14.880 the actual mechanism. It has to do with the repolarization 00:47:14.880 --> 00:47:17.639 phase of the cardiac action potential. Potassium 00:47:17.639 --> 00:47:19.579 is responsible for flowing out of the cell to 00:47:19.579 --> 00:47:21.719 restore the negative electrical charge after 00:47:21.719 --> 00:47:25.079 a heartbeat. So the reset. Exactly. If your serum 00:47:25.079 --> 00:47:28.340 potassium is low, This efflux is delayed. The 00:47:28.340 --> 00:47:31.119 repolarization phase is prolonged. This leaves 00:47:31.119 --> 00:47:34.239 the cardiac cells in a vulnerable, hyper -excitable 00:47:34.239 --> 00:47:37.019 state for a longer period. And that leads directly 00:47:37.019 --> 00:47:39.420 to the R on T phenomenon, doesn't it? Exactly. 00:47:39.659 --> 00:47:41.780 The R on T phenomenon is the classic trigger 00:47:41.780 --> 00:47:44.559 for lethal dysrhythmias. The T wave represents 00:47:44.559 --> 00:47:47.800 ventricular repolarization. The peak and down 00:47:47.800 --> 00:47:50.000 slope of the T wave is the relative refractory 00:47:50.000 --> 00:47:52.460 period. The cells are resetting and they are 00:47:52.460 --> 00:47:55.219 incredibly unstable. So if a random impulse hits 00:47:55.219 --> 00:47:58.019 them then? If a random rogue electrical impulse, 00:47:58.119 --> 00:48:00.619 a PVC, happens to fire and land exactly on that 00:48:00.619 --> 00:48:03.119 vulnerable T -ways, it shatters the electrical 00:48:03.119 --> 00:48:05.659 grid. It sends the ventricles into a rapid chaotic 00:48:05.659 --> 00:48:08.719 tailspin of ventricular tachycardia or fibrillation. 00:48:09.000 --> 00:48:11.360 Is there any physiological compensation for this? 00:48:11.659 --> 00:48:14.860 Like, at all? Absolutely none. The decompensation 00:48:14.860 --> 00:48:17.679 is instantaneous. Think about the physical mechanics 00:48:17.679 --> 00:48:20.099 of the pump. Because the ventricles are beating 00:48:20.099 --> 00:48:23.460 250 times a minute in VT or just violently vibrating 00:48:23.460 --> 00:48:26.840 in VF, diastole essentially ceases to exist. 00:48:26.960 --> 00:48:29.579 There's no relaxation phase. Right. If the ventricles 00:48:29.579 --> 00:48:31.760 never relax, they never fill with blood. If there's 00:48:31.760 --> 00:48:33.340 no blood in the chamber, there's no blood to 00:48:33.340 --> 00:48:35.900 pump out to the body. Cardiac output drops to 00:48:35.900 --> 00:48:38.539 absolute zero immediately. So the clinical findings 00:48:38.539 --> 00:48:40.539 are exactly what you'd expect when blood flow 00:48:40.539 --> 00:48:43.119 to the brain and body stops. Yes. The patient 00:48:43.119 --> 00:48:46.780 is completely unresponsive, pulseless, apneic, 00:48:46.820 --> 00:48:49.099 and clinically dead. Let's talk assessment. Are 00:48:49.099 --> 00:48:51.079 there any early warning signs before this happens, 00:48:51.139 --> 00:48:53.440 or is it just bam, they're dead? Early on, you 00:48:53.440 --> 00:48:56.039 might see warning signs on the monitor. Frequent 00:48:56.039 --> 00:48:59.420 PVCs or runs of two or three PVCs together, but 00:48:59.420 --> 00:49:01.800 often it is sudden. The classic finding on the 00:49:01.800 --> 00:49:04.980 monitor for VT is wide distorted QRS complexes. 00:49:05.440 --> 00:49:08.639 For VF, it's just chaotic, wavy, meaningless 00:49:08.639 --> 00:49:11.739 lines. And the dangerous finding is the loss 00:49:11.739 --> 00:49:14.210 of a pulse. But I want to clarify something. 00:49:14.449 --> 00:49:17.190 Can a patient in ventricular tachycardia still 00:49:17.190 --> 00:49:19.449 have a pulse? This is a critical distinction. 00:49:19.989 --> 00:49:23.050 Yes, for a very brief period a patient in VT 00:49:23.050 --> 00:49:25.590 might have a pulse and be conscious if their 00:49:25.590 --> 00:49:27.610 heart is still managing to squeeze out a tiny 00:49:27.610 --> 00:49:30.409 fraction of blood. We call that stable VT. Okay. 00:49:30.570 --> 00:49:33.309 But it will rapidly deteriorate into pulseless 00:49:33.309 --> 00:49:36.679 VT. Ventricular fibrillation, however, never 00:49:36.679 --> 00:49:40.039 has a pulse. VF is always clinical death. Diagnostics. 00:49:40.099 --> 00:49:42.619 We obviously aren't waiting for a 12 lead ECG 00:49:42.619 --> 00:49:45.159 or lab results to confirm this. No. You read 00:49:45.159 --> 00:49:46.920 the rhythm on the monitor in front of you. VT 00:49:46.920 --> 00:49:50.360 looks like a continuous rapid row of wide, bizarre 00:49:50.360 --> 00:49:53.900 QRS complexes greater than 0 .12 seconds wide. 00:49:54.300 --> 00:49:56.280 They often look perfectly identical to each other, 00:49:56.300 --> 00:49:59.280 which we call monomorphic VT. The T wave is usually 00:49:59.280 --> 00:50:01.059 deflected in the opposite direction of the QRS. 00:50:01.119 --> 00:50:03.739 And VF? VF shows no measurable waves whatsoever. 00:50:03.760 --> 00:50:05.599 it looks like electrical static. Okay, I walk 00:50:05.599 --> 00:50:08.800 into the room, the monitor shows VFib. ADPIE 00:50:08.800 --> 00:50:11.460 time. What are my priority nursing actions? First, 00:50:11.699 --> 00:50:14.460 next, then. First, you check the patient, not 00:50:14.460 --> 00:50:17.519 the monitor. Do they respond? Do they have a 00:50:17.519 --> 00:50:21.179 carotid pulse? You must verify pulselessness. 00:50:21.760 --> 00:50:24.920 Then XT. If there is no pulse, you initiate high 00:50:24.920 --> 00:50:27.559 quality CPR immediately and call for help hit 00:50:27.559 --> 00:50:30.840 the code blue button. Right, and then? Then, 00:50:30.989 --> 00:50:32.889 You must defibrillate the patient as rapidly 00:50:32.889 --> 00:50:35.550 as possible, ideally within two minutes of the 00:50:35.550 --> 00:50:38.369 arrest. Let's talk about the physics of defibrillation 00:50:38.369 --> 00:50:41.349 versus cardioversion. We discussed synchronized 00:50:41.349 --> 00:50:44.309 cardioversion earlier for AFib, but here we are 00:50:44.309 --> 00:50:46.070 using defibrillation. What is the difference? 00:50:46.230 --> 00:50:49.230 Defibrillation is a massive unsynchronized blast 00:50:49.230 --> 00:50:52.250 of raw electricity. We usually use a biphasic 00:50:52.250 --> 00:50:55.329 defibrillator, delivering between 120 and 200 00:50:55.329 --> 00:50:57.889 joules of energy. The electricity travels from 00:50:57.889 --> 00:51:00.289 one pad to the other, completely depolarizing 00:51:00.289 --> 00:51:02.710 every single cell in the myocardium simultaneously. 00:51:03.010 --> 00:51:04.809 You're trying to flatline them, basically. Exactly. 00:51:04.929 --> 00:51:06.550 That's a great way to think about it. You are 00:51:06.550 --> 00:51:08.849 causing a momentary total electrical standstill. 00:51:09.409 --> 00:51:11.389 The goal is to shut down all the chaotic rogue 00:51:11.389 --> 00:51:13.750 cells at once with the hope that the main breaker 00:51:13.750 --> 00:51:16.269 panel, the SA node, will wake up, realize it's 00:51:16.269 --> 00:51:18.500 quiet, and take back control of the grid. So 00:51:18.500 --> 00:51:21.139 in defibrillation, the sync button is absolutely 00:51:21.139 --> 00:51:23.719 off. Exactly. Because if you used cardioversion. 00:51:23.820 --> 00:51:26.260 If you synchronize cardioversion, the machine 00:51:26.260 --> 00:51:29.699 looks for a QRS complex to time the shock. In 00:51:29.699 --> 00:51:32.500 VFIV, there are no QRS complexes. The machine 00:51:32.500 --> 00:51:35.099 will just sit there waiting forever, and it will 00:51:35.099 --> 00:51:37.119 never deliver the shock while your patient dies. 00:51:37.519 --> 00:51:40.039 Never use synchronized cardioversion on a pulseless 00:51:40.039 --> 00:51:42.599 patient. During the code, what medications are 00:51:42.599 --> 00:51:45.059 we pushing? Epinephrine is our primary drug. 00:51:45.059 --> 00:51:47.420 We push one milligram every three to five minutes. 00:51:47.579 --> 00:51:51.659 Epinephrine is a potent alpha -1 adrenergic agonist. 00:51:52.139 --> 00:51:54.639 It causes profound peripheral vasoconstriction. 00:51:54.900 --> 00:51:57.159 OK, wait. Why do we want vasoconstriction during 00:51:57.159 --> 00:52:00.780 cardiac arrest? Great question. By clamping down 00:52:00.780 --> 00:52:03.139 all the blood vessels in the arms and legs, it 00:52:03.139 --> 00:52:05.260 forces whatever blood we are generated with CPR 00:52:05.260 --> 00:52:07.699 directly to the brain and the coronary arteries. 00:52:08.179 --> 00:52:10.900 We're maximizing central perfusion. Oh, that 00:52:10.900 --> 00:52:13.480 makes sense. What about antiarrhythmics to fix 00:52:13.480 --> 00:52:16.340 the chaotic tissue? We use ameturone or sometimes 00:52:16.340 --> 00:52:19.000 lidocaine. Ameturone prolongs the action potential, 00:52:19.039 --> 00:52:21.860 trying to stabilize that hyper excitable ventricular 00:52:21.860 --> 00:52:24.440 tissue. And magnesium. You mentioned low magnesium 00:52:24.440 --> 00:52:27.139 earlier. Yes. If the patient is in a specific 00:52:27.139 --> 00:52:30.119 type of VT called torsades de pointe, where the 00:52:30.119 --> 00:52:32.400 wide complexes twist up and down like a party 00:52:32.400 --> 00:52:36.440 ribbon, the definitive drug is IV magnesium sulfate. 00:52:37.260 --> 00:52:40.059 Torsades is specifically caused by a prolonged 00:52:40.059 --> 00:52:43.460 QT interval and magnesium stabilizes the cellular 00:52:43.460 --> 00:52:46.159 membrane and shortens that repolarization phase. 00:52:46.460 --> 00:52:48.480 Complications here are obvious. If we don't fix 00:52:48.480 --> 00:52:50.659 it, they stay dead. The major complication is 00:52:50.659 --> 00:52:53.719 anoxic brain injury. Every minute without CPR 00:52:53.719 --> 00:52:56.179 and defibrillation decreases the chance of survival 00:52:56.179 --> 00:52:59.099 by 7 to 10 percent. Your nursing action is to 00:52:59.099 --> 00:53:02.679 ensure high quality CPR, push hard, push fast, 00:53:03.000 --> 00:53:04.980 and minimize interruptions to chest compressions 00:53:04.980 --> 00:53:07.300 to preserve that neurological function. What 00:53:07.300 --> 00:53:10.039 are the biggest novice mistakes or exam traps 00:53:10.039 --> 00:53:13.260 when dealing with VT and VF? Two major traps. 00:53:13.659 --> 00:53:15.800 First, the ultimate novice error. treating the 00:53:15.800 --> 00:53:17.800 monitor instead of the patient. Artifact from 00:53:17.800 --> 00:53:19.880 the patient brushing their teeth or a loose lead 00:53:19.880 --> 00:53:22.219 wire jiggling around can look exactly like coarse 00:53:22.219 --> 00:53:24.519 V fib on the screen. Oh, man. If you call the 00:53:24.519 --> 00:53:26.159 code and try to shock a patient who is sitting 00:53:26.159 --> 00:53:28.460 up talking to you, it's a disaster. Always check 00:53:28.460 --> 00:53:30.400 the patient's pulse first. And the second trap. 00:53:30.519 --> 00:53:33.219 If the patient has a permanent pacemaker or ICD 00:53:33.219 --> 00:53:36.480 implanted under their skin, never place the defibrillator 00:53:36.480 --> 00:53:39.280 pads directly over the device. The metal generator 00:53:39.280 --> 00:53:41.619 will absorb the shock, destroying the device 00:53:41.619 --> 00:53:43.539 and preventing the electricity from reaching 00:53:43.539 --> 00:53:45.820 the heart. Place the pad at least an inch away 00:53:45.820 --> 00:53:48.159 or use an anterior -posterior pad placement. 00:53:48.480 --> 00:53:50.880 Let's do intensivist thinking for the code blue 00:53:50.880 --> 00:53:54.739 killers. Problem. Lethal ventricular chaos. Failing 00:53:54.739 --> 00:53:58.230 physiology. No blood is pumping, diastole is 00:53:58.230 --> 00:54:00.349 eliminated, and the brain is actively dying. 00:54:00.889 --> 00:54:03.710 Immediate threat. Irreversible biological death. 00:54:03.750 --> 00:54:06.409 Got it. Intervention. You become the mechanical 00:54:06.409 --> 00:54:09.710 pump by providing high quality CPR and you reset 00:54:09.710 --> 00:54:11.670 the electrical grid with rapid defibrillation. 00:54:11.820 --> 00:54:14.059 reassessment, pulse check, and rhythm check every 00:54:14.059 --> 00:54:16.420 two minutes. Okay, so locking in the five core 00:54:16.420 --> 00:54:18.739 things to remember. The patho is the ventricles 00:54:18.739 --> 00:54:20.980 quivering or beating too fast to fill, dropping 00:54:20.980 --> 00:54:23.659 output to zero. The assessment is pulselessness 00:54:23.659 --> 00:54:26.300 and apnea. The complication is biological death. 00:54:26.800 --> 00:54:29.059 The priority action is starting CPR immediately. 00:54:29.280 --> 00:54:31.699 And the definitive treatment is rapid unsynchronized 00:54:31.699 --> 00:54:34.409 defibrillation. The clinical picture. A patient 00:54:34.409 --> 00:54:37.590 with severe hypokalemia suddenly loses consciousness, 00:54:38.150 --> 00:54:40.849 loses their pulse, and shows wide, continuous, 00:54:41.070 --> 00:54:43.349 bizarre waveforms on the monitor. So if you see 00:54:43.349 --> 00:54:46.110 chaotic, irregular waveforms with no discernible 00:54:46.110 --> 00:54:49.269 QRS, think ventricular fibrillation and immediately 00:54:49.269 --> 00:54:52.030 start CPR and defibrillate. Absolutely. Okay, 00:54:52.130 --> 00:54:53.829 that brings us to the next scenario, which I 00:54:53.829 --> 00:54:55.889 think is conceptually the trickiest one for a 00:54:55.889 --> 00:54:58.309 lot of people to grasp. What if the monitor shows 00:54:58.309 --> 00:55:01.119 a rhythm? Maybe even a perfectly normal, beautiful 00:55:01.119 --> 00:55:03.460 sinus rhythm, but the patient looks completely 00:55:03.460 --> 00:55:06.340 dead. Or what if there's just a flat line? We 00:55:06.340 --> 00:55:08.460 need to talk about PEA, pulseless electrical 00:55:08.460 --> 00:55:11.139 activity, and a systole. This scenario is the 00:55:11.139 --> 00:55:14.300 ultimate deception in the ICU. The 80 -20 overview 00:55:14.300 --> 00:55:16.619 here is that PEA is the presence of organized 00:55:16.619 --> 00:55:18.880 electrical activity on the monitor, but the heart 00:55:18.880 --> 00:55:20.860 muscle is failing to respond mechanically. There 00:55:20.860 --> 00:55:23.159 is no pulse. And a systole? A systole is the 00:55:23.159 --> 00:55:25.599 total catastrophic absence of both electrical 00:55:25.599 --> 00:55:28.949 and mechanical activity. It is a flat line. The 00:55:28.949 --> 00:55:31.070 absolute most crucial fact you must internalize 00:55:31.070 --> 00:55:34.210 is this. Electricity, meaning a shock from a 00:55:34.210 --> 00:55:36.570 defibrillator, will not think either of these. 00:55:36.789 --> 00:55:39.170 They are non -shockable rhythms. Let's really 00:55:39.170 --> 00:55:42.250 dig into the pathophysiology of PEA. Because 00:55:42.250 --> 00:55:45.289 how is it physically possible that the electrical 00:55:45.289 --> 00:55:47.789 grid is working perfectly, but the pump isn't 00:55:47.789 --> 00:55:50.050 pumping? Let's go back to our house metaphor. 00:55:50.750 --> 00:55:53.250 The main breaker panel is working. The wires 00:55:53.250 --> 00:55:55.269 in the walls are transmitting the electrical 00:55:55.269 --> 00:55:57.550 current perfectly. But down in the basement, 00:55:57.889 --> 00:56:00.550 the physical water pump is completely dry, or 00:56:00.550 --> 00:56:03.170 it has been crushed by a fallen beam. The electricity 00:56:03.170 --> 00:56:05.730 is telling the pump to turn on, but it mechanically 00:56:05.730 --> 00:56:08.750 cannot move water. Exactly. So what causes the 00:56:08.750 --> 00:56:11.409 pump to fail if the electricity is fine? We categorize 00:56:11.409 --> 00:56:14.369 the triggers as the H's and T's. Hypovolemia 00:56:14.369 --> 00:56:17.579 is a classic example. Massive blood loss. If 00:56:17.579 --> 00:56:19.940 a trauma patient bleeds out, their heart is completely 00:56:19.940 --> 00:56:22.500 empty. The SA node is frantically sending out 00:56:22.500 --> 00:56:24.320 electrical signals, which look like a normal 00:56:24.320 --> 00:56:26.840 sinus rhythm on a monitor, but there is no physical 00:56:26.840 --> 00:56:29.900 blood to pump. The cardiac output is zero because 00:56:29.900 --> 00:56:32.480 the preload is zero. Wow. What about the T's? 00:56:32.739 --> 00:56:35.500 A great example is cardiac tamponade. This is 00:56:35.500 --> 00:56:38.239 when fluid or blood rapidly fills the pericardial 00:56:38.239 --> 00:56:41.360 sac surrounding the heart. The fluid exerts massive 00:56:41.360 --> 00:56:43.739 physical pressure on the myocardium, physically 00:56:43.739 --> 00:56:45.739 crushing the ventricles so they cannot expand 00:56:45.739 --> 00:56:48.369 during diastole. Oh, so, again, the electrical 00:56:48.369 --> 00:56:50.710 signal fires normally, but the muscle is physically 00:56:50.710 --> 00:56:53.869 trapped and cannot squeeze. Exactly. Other causes 00:56:53.869 --> 00:56:57.090 include profound hypoxia, severe acidosis, or 00:56:57.090 --> 00:56:59.670 tension pneumothorax. So the physiologic change 00:56:59.670 --> 00:57:01.949 is that the muscle is either deprived of volume, 00:57:02.309 --> 00:57:04.869 deprived of oxygen, or physically compressed, 00:57:05.230 --> 00:57:07.789 rendering it incapable of responding to the electrical 00:57:07.789 --> 00:57:10.690 command. Exactly. The decompensation is identical 00:57:10.690 --> 00:57:14.230 to VFib. Total cardiovascular collapse. The clinical 00:57:14.230 --> 00:57:16.889 findings are an unresponsive, pulseless, and 00:57:16.889 --> 00:57:19.110 apneic patient. Assessment is straightforward. 00:57:19.489 --> 00:57:21.969 Classic and dangerous findings are no pulse, 00:57:22.010 --> 00:57:24.909 no breathing. What about diagnostics? How does 00:57:24.909 --> 00:57:27.269 this actually look on the grid? A systole is 00:57:27.269 --> 00:57:30.010 a flat line, just a slight wandering baseline 00:57:30.010 --> 00:57:33.710 with zero electrical complexes. PEA, however, 00:57:34.170 --> 00:57:36.090 can look like absolutely any organized rhythm 00:57:36.090 --> 00:57:38.829 on the monitor. It can look like sinus bradycardia, 00:57:39.210 --> 00:57:41.429 a junctional rhythm, or even a perfect normal 00:57:41.429 --> 00:57:43.789 sinus rhythm at 80 beats per minute. Which is 00:57:43.789 --> 00:57:45.989 wild. That is why you can never trust a monitor 00:57:45.989 --> 00:57:48.989 in isolation. you must check the patient. Priority 00:57:48.989 --> 00:57:51.869 nursing actions. I walk in, see a normal rhythm, 00:57:51.929 --> 00:57:54.889 but my patient is blue and pulseless. First, 00:57:55.329 --> 00:57:58.610 next T, then... First, you verify pulselessness. 00:57:59.150 --> 00:58:01.969 If the monitor shows a systole, you must verify 00:58:01.969 --> 00:58:04.449 that flat line in at least two different ECG 00:58:04.449 --> 00:58:06.110 leads to ensure it's not just a disconnected 00:58:06.110 --> 00:58:10.340 wire. Next T, you initiate high quality CPR immediately. 00:58:10.699 --> 00:58:12.260 You have to be on the mechanical pump because 00:58:12.260 --> 00:58:15.119 theirs has failed. And then? Then, you push epinephrine 00:58:15.119 --> 00:58:17.539 and you start acting like an intensive care detective 00:58:17.539 --> 00:58:19.940 to find and revert the underlying cause. Let's 00:58:19.940 --> 00:58:22.699 talk medications. We push epinephrine but no 00:58:22.699 --> 00:58:24.579 amutorone, right? Why? Correct. Just epinephrine. 00:58:24.619 --> 00:58:26.820 Remember the pharmacology? Amutorone is designed 00:58:26.820 --> 00:58:29.920 to stabilize highly irritable chaotic electrical 00:58:29.920 --> 00:58:33.079 tissue in VT or VF. In PEA and assistally, the 00:58:33.079 --> 00:58:35.760 tissue isn't irritable. It's dead, dying or empty. 00:58:36.139 --> 00:58:40.059 There's no electrical chaos to fix. We use epinephrine 00:58:40.059 --> 00:58:42.559 purely for its massive vasoconstrictive alpha 00:58:42.559 --> 00:58:45.619 -1 effects. We are trying to aggressively clamp 00:58:45.619 --> 00:58:48.260 down the peripheral arteries to increase the 00:58:48.260 --> 00:58:50.960 aortic diastolic pressure, which forces blood 00:58:50.960 --> 00:58:53.380 flow into the coronary arteries to feed the dying 00:58:53.380 --> 00:58:55.719 heart muscle. But epinephrine alone isn't going 00:58:55.719 --> 00:58:58.739 to fix PEA, is it? No, absolutely not. Epinephrine 00:58:58.739 --> 00:59:01.320 just dies you time. This is where hemodynamics 00:59:01.320 --> 00:59:04.730 and fluids come in. If the PEA is caused by hypovolemia 00:59:04.730 --> 00:59:07.050 from a massive hemorrhage, you can do perfect 00:59:07.050 --> 00:59:10.150 CPR and push epinephrine all day long, and the 00:59:10.150 --> 00:59:12.090 patient will still die. You have to fix the plumbing. 00:59:12.510 --> 00:59:14.769 Exactly. The definitive treatment is to rapidly 00:59:14.769 --> 00:59:17.269 infuse massive blood transfusions and IV fluids 00:59:17.269 --> 00:59:20.050 to refill the pump. If the cause is a tension 00:59:20.050 --> 00:59:22.969 pneumothorax, the provider must perform an immediate 00:59:22.969 --> 00:59:25.030 needle decompression to release the trapped air. 00:59:25.329 --> 00:59:27.630 You have to fix the H or the T. What's the biggest 00:59:27.630 --> 00:59:30.610 exam trap or clinical error here? I cannot emphasize 00:59:30.610 --> 00:59:32.889 this enough. The ultimate error is shocking, 00:59:33.090 --> 00:59:36.409 asystole, or PEA. Hollywood gets this wrong constantly. 00:59:36.809 --> 00:59:39.510 You see a dramatic medical scene on TV, the monitor 00:59:39.510 --> 00:59:43.190 goes flat, the doctor yells clear, and they shock 00:59:43.190 --> 00:59:45.070 the flat line. Right, you see that all the time. 00:59:45.110 --> 00:59:47.949 That is medical illiteracy. Because shocking 00:59:47.949 --> 00:59:51.590 only fixes electrical chaos. Exactly. Defibrillation 00:59:51.590 --> 00:59:54.239 is designed to stop a chaotic rhythm. so the 00:59:54.239 --> 00:59:57.059 SA node can reset. In the systole, there is no 00:59:57.059 --> 00:59:59.980 rhythm to stop. The grid is already dead. So 00:59:59.980 --> 01:00:02.420 shocking. If you shock a dead heart, you are 01:00:02.420 --> 01:00:04.559 just firing high -energy electrical burns into 01:00:04.559 --> 01:00:07.119 dead tissue, causing further myocardial damage 01:00:07.119 --> 01:00:09.920 and completely eliminating any microscopic chance 01:00:09.920 --> 01:00:12.760 of recovery. Never shock a flat line. That makes 01:00:12.760 --> 01:00:15.239 total sense. Intensive is thinking for the flat 01:00:15.239 --> 01:00:17.650 lines. Problem. A dead or empty mechanical pump. 01:00:17.829 --> 01:00:20.630 Feeling physiology. There is no mechanical response 01:00:20.630 --> 01:00:22.869 to the electrical grid leading to zero cardiac 01:00:22.869 --> 01:00:25.909 output. Immediate threat. Irreversible brain 01:00:25.909 --> 01:00:28.730 death. And intervention. Intervention. You become 01:00:28.730 --> 01:00:31.889 the pump via CPR. You push epinephrine to preserve 01:00:31.889 --> 01:00:34.269 coronary perfusion. And you desperately search 01:00:34.269 --> 01:00:37.289 for the underlying H's and T's. Reassessment. 01:00:37.829 --> 01:00:39.809 Frequent pulse checks and lab results to guide 01:00:39.809 --> 01:00:41.969 your detective work. So the five core things 01:00:41.969 --> 01:00:44.480 to remember. The patho is that the electrical 01:00:44.480 --> 01:00:46.960 system might work, but the mechanical pump has 01:00:46.960 --> 01:00:49.920 failed due to a systemic insult. The assessment 01:00:49.920 --> 01:00:52.619 is no pulse despite an organized rhythm on the 01:00:52.619 --> 01:00:55.900 screen. The complication is death. Priority action 01:00:55.900 --> 01:00:58.880 is CPR and epinephrine. And the absolute most 01:00:58.880 --> 01:01:01.079 important treatment is finding and reversing 01:01:01.079 --> 01:01:03.519 the underlying cause. Perfect. The clinical picture. 01:01:04.139 --> 01:01:06.300 A trauma patient with massive internal bleeding 01:01:06.300 --> 01:01:08.659 shows a perfect normal sinus rhythm on the monitor 01:01:08.659 --> 01:01:11.860 but has absolutely no palpable pulse. So if you 01:01:11.860 --> 01:01:13.980 see an organized rhythm but the patient is pulseless, 01:01:14.179 --> 01:01:17.619 think PEA, immediately start CPR, and push epinephrine. 01:01:17.659 --> 01:01:20.559 Do not shock. Exactly. Do not shock. That brings 01:01:20.559 --> 01:01:23.159 us to our final scenario. We spent this entire 01:01:23.159 --> 01:01:25.519 time talking about the heart's natural electrical 01:01:25.519 --> 01:01:28.340 grid failing. But to wrap this up, let's talk 01:01:28.340 --> 01:01:30.579 about what happens when the very hardware we 01:01:30.579 --> 01:01:33.099 implant to save these patients starts failing 01:01:33.099 --> 01:01:37.320 on the job. Let's discuss pacemaker and ICD malfunctions. 01:01:37.500 --> 01:01:39.840 This requires critical bedside troubleshooting, 01:01:40.440 --> 01:01:44.119 the 80 -20 overview. Pacemakers are devices designed 01:01:44.119 --> 01:01:46.659 to pace a slow, heart -treating things like our 01:01:46.659 --> 01:01:50.820 third -degree AV blocks. ICDs or implantable 01:01:50.820 --> 01:01:53.539 cardioverted defibrillators are designed to monitor 01:01:53.539 --> 01:01:56.539 for and automatically shock lethal rhythms like 01:01:56.539 --> 01:02:00.239 VT or VF. Both rely on synthetic wires and batteries. 01:02:00.500 --> 01:02:03.059 And both can fail. The big three malfunctions 01:02:03.059 --> 01:02:05.699 you must memorize are failure to sense, failure 01:02:05.699 --> 01:02:08.519 to capture, and failure to pace. What triggers 01:02:08.519 --> 01:02:10.400 these million dollar devices to fail? What's 01:02:10.400 --> 01:02:12.579 the pathophysiology of hardware failure? The 01:02:12.579 --> 01:02:14.559 trigger is usually mechanical. The battery inside 01:02:14.559 --> 01:02:17.059 the generator depletes over time. or the lead 01:02:17.059 --> 01:02:18.980 wire, the synthetic wire running from the device 01:02:18.980 --> 01:02:21.000 down into the right ventricle, gets physically 01:02:21.000 --> 01:02:22.940 dislodged from the heart wall. Okay, what else? 01:02:23.420 --> 01:02:26.119 Another major physiological cause is fibrosis. 01:02:26.480 --> 01:02:28.860 Over time, the body attacks the foreign metal 01:02:28.860 --> 01:02:32.059 wire and forms dense scar tissue right at the 01:02:32.059 --> 01:02:34.960 tip where it touches the myocardium. This scar 01:02:34.960 --> 01:02:38.380 tissue acts as an insulator, drastically increasing 01:02:38.380 --> 01:02:41.159 the electrical impedance. Ah, so the electrical 01:02:41.159 --> 01:02:43.869 current from the pacemaker can't... punch through 01:02:43.869 --> 01:02:46.849 the scar tissue to reach the muscle cells. Precisely. 01:02:47.289 --> 01:02:50.590 Let's break down the three failures. In failure 01:02:50.590 --> 01:02:53.869 to sense, the device becomes blind. It is supposed 01:02:53.869 --> 01:02:56.309 to monitor the patient's intrinsic millivolts, 01:02:56.670 --> 01:02:58.510 but it fails to see the patient's own natural 01:02:58.510 --> 01:03:00.769 heartbeat, so it just fires its electrical spikes 01:03:00.769 --> 01:03:03.090 randomly. Okay, blind. What's failure to capture? 01:03:03.289 --> 01:03:05.610 In failure to capture, the device is weak. It 01:03:05.610 --> 01:03:08.170 fires precisely when it's supposed to, but the 01:03:08.170 --> 01:03:10.250 current, the milliamps, isn't strong enough to 01:03:10.250 --> 01:03:12.530 penetrate that scar tissue, so the muscle never 01:03:12.530 --> 01:03:15.130 contracts. And failure to pace. In failure to 01:03:15.130 --> 01:03:17.170 pace, the device is completely dead. The heart 01:03:17.170 --> 01:03:19.309 rate drops, but the device never sends a signal 01:03:19.309 --> 01:03:22.210 at all. So if the device fails, the patient just 01:03:22.210 --> 01:03:24.510 reverts back to their original lethal dysrhythmia. 01:03:25.030 --> 01:03:28.150 They experience profound bradycardia, syncope, 01:03:28.409 --> 01:03:31.099 or worse. How do we assess this on the monitor? 01:03:31.300 --> 01:03:33.079 We're looking at the pacer spikes, right? Yes. 01:03:33.440 --> 01:03:35.880 A pacer spike is a sharp, distinct vertical line 01:03:35.880 --> 01:03:38.800 on the ECG. In failure to capture the weak device, 01:03:39.360 --> 01:03:41.780 you will see a bright pacer spike, but it is 01:03:41.780 --> 01:03:44.719 followed by absolutely nothing. A flat line. 01:03:45.219 --> 01:03:47.760 No QRS complex follows the spike. Okay, weak 01:03:47.760 --> 01:03:50.659 device, no QRS. What about the blind one? In 01:03:50.659 --> 01:03:53.059 failure to sense, you will see pacer spikes landing 01:03:53.059 --> 01:03:55.579 randomly all over the ECG, completely out of 01:03:55.579 --> 01:03:58.019 sync, sometimes landing right on top of the patient's 01:03:58.019 --> 01:04:00.340 all -natural QRS complexes. And the dead one, 01:04:00.539 --> 01:04:02.699 failure to pace. The patient's heart rate drops 01:04:02.699 --> 01:04:05.400 below the set limit, say down to 40, but there 01:04:05.400 --> 01:04:07.519 are absolutely no pacer spikes visible to try 01:04:07.519 --> 01:04:09.559 to help. So if I'm managing a patient with a 01:04:09.559 --> 01:04:12.280 temporary transvenous pacemaker in the ICU and 01:04:12.280 --> 01:04:14.599 I see failure to capture on the monitor, what 01:04:14.599 --> 01:04:17.619 are my priority nursing actions? First, you check 01:04:17.619 --> 01:04:20.440 the physical connections. Trace the wire from 01:04:20.440 --> 01:04:22.639 the patient's neck down to the external generator 01:04:22.639 --> 01:04:25.579 box. Make sure the battery is good and the pins 01:04:25.579 --> 01:04:28.619 are locked in. Loose wires happen constantly. 01:04:28.900 --> 01:04:32.000 Next T. Next T. You adjust the settings based 01:04:32.000 --> 01:04:35.320 on the failure. If it's failure to capture, meaning 01:04:35.320 --> 01:04:37.760 the signal is too weak, you turn up the milliamps 01:04:37.760 --> 01:04:40.059 dial to give the device more electrical juice 01:04:40.059 --> 01:04:41.880 to punch through the resistance. And if it's 01:04:41.880 --> 01:04:44.440 blind? If it's failure to sense, you adjust the 01:04:44.440 --> 01:04:47.039 sensitivity dial, measured in millivolts, so 01:04:47.039 --> 01:04:49.219 the machine can see the heart better. What if 01:04:49.219 --> 01:04:51.820 turning the dials doesn't work? Then you use 01:04:51.820 --> 01:04:55.380 a fantastic physical nursing trick. Physically 01:04:55.380 --> 01:04:57.599 roll the patient onto their left side. Wait, 01:04:57.599 --> 01:05:00.340 really? Just roll them? Yeah. Gravity will pull 01:05:00.340 --> 01:05:02.960 the heavy ventricular muscle and the free -floating 01:05:02.960 --> 01:05:05.679 transvenous wire together, promoting better physical 01:05:05.679 --> 01:05:08.280 contact between the metal tip and the endocardium. 01:05:08.420 --> 01:05:11.119 That is such a cool trick. What's the most dangerous 01:05:11.119 --> 01:05:13.599 complication of these failures? The most lethal 01:05:13.599 --> 01:05:17.019 complication stems from failure to sense. Remember 01:05:17.019 --> 01:05:19.460 the R on T phenomenon we discussed with ventricular 01:05:19.460 --> 01:05:22.860 fibrillation? Where a random spark hits the vulnerable 01:05:22.860 --> 01:05:26.539 T wave and shatters the grid. Exactly. If the 01:05:26.539 --> 01:05:29.139 pacemaker is blind, it might randomly fire a 01:05:29.139 --> 01:05:32.280 high energy pacing spike that lands exactly on 01:05:32.280 --> 01:05:34.500 the vulnerable T wave of the patient's natural 01:05:34.500 --> 01:05:37.519 beat. Oh no. The pacemaker itself triggers the 01:05:37.519 --> 01:05:40.099 RNT phenomenon, throwing the patient directly 01:05:40.099 --> 01:05:43.880 into iatrogenic ventricular fibrillation. Your 01:05:43.880 --> 01:05:46.880 action is to immediately start CPR and defibrillate 01:05:46.880 --> 01:05:49.000 the patient you just accidentally coded. That 01:05:49.000 --> 01:05:51.880 is the ultimate nightmare scenario. Let's talk 01:05:51.880 --> 01:05:53.800 about patient education for permanent pacemakers 01:05:53.800 --> 01:05:56.300 because I know that is heavily tested and crucial 01:05:56.300 --> 01:05:58.480 for long -term survival. Patient teaching is 01:05:58.480 --> 01:06:02.119 paramount. First, infection control. Keep the 01:06:02.119 --> 01:06:04.139 surgical incision perfectly dry for at least 01:06:04.139 --> 01:06:07.719 four days. Second, mechanical protection. The 01:06:07.719 --> 01:06:09.760 patient must not lift the arm on the side of 01:06:09.760 --> 01:06:11.340 the pacemaker above their shoulder for several 01:06:11.340 --> 01:06:13.559 weeks. Why? What happens? If they reach up to 01:06:13.559 --> 01:06:15.639 grab something off a high shelf, the muscle movement 01:06:15.639 --> 01:06:17.840 will literally rip the newly implanted fragile 01:06:17.840 --> 01:06:20.000 lead wire right out of the ventricular wall. 01:06:20.340 --> 01:06:22.820 Yikes. Okay. What about environmental hazards 01:06:22.820 --> 01:06:25.420 like magnets, microwaves? Microwaves are totally 01:06:25.420 --> 01:06:28.579 safe. That's an archaic myth from the 1970s. 01:06:28.679 --> 01:06:31.829 However, MRI machines are generally a hard contraindication. 01:06:31.989 --> 01:06:34.570 Because of the magnets? Right. The massive magnetic 01:06:34.570 --> 01:06:36.869 field of an MRI can literally heat the metal 01:06:36.869 --> 01:06:40.230 wires inside the heart, burn the tissue, or physically 01:06:40.230 --> 01:06:43.050 rip the generator out of the chest pocket. Unless 01:06:43.050 --> 01:06:46.730 the patient has a very specific modern MRI conditional 01:06:46.730 --> 01:06:49.650 device, they cannot go into that scanner. Let's 01:06:49.650 --> 01:06:52.010 run the intensivist thinking for hardware failure. 01:06:52.289 --> 01:06:55.190 Problem. The synthetic hardware is failing to 01:06:55.190 --> 01:06:57.929 read or stimulate the heart. Failing physiology. 01:06:58.119 --> 01:07:00.880 a return of the patient's underlying lethal dysrhythmia, 01:07:01.179 --> 01:07:03.860 and a massive drop in cardiac output. Immediate 01:07:03.860 --> 01:07:06.519 threat, syncope, or pacemaker -induced cardiac 01:07:06.519 --> 01:07:09.019 arrest. And the intervention. Intervention, troubleshoot 01:07:09.019 --> 01:07:11.400 the external device settings by adjusting milliamps 01:07:11.400 --> 01:07:14.460 or sensitivity, and support the patient's ABCs. 01:07:14.679 --> 01:07:17.699 Reassessment. Continuous ECG monitoring to ensure 01:07:17.699 --> 01:07:20.860 every pacing spike is followed by a QRS complex. 01:07:21.139 --> 01:07:23.039 So if I'm writing down the five key takeaways, 01:07:23.460 --> 01:07:25.619 the patho is that the device fails to monitor, 01:07:25.820 --> 01:07:27.800 fire, or stimulate the muscle due to battery, 01:07:27.980 --> 01:07:30.760 wire, or impedance issues. The assessment is 01:07:30.760 --> 01:07:32.820 a heart rate dropping below the set limit leading 01:07:32.820 --> 01:07:36.619 to syncope. The complication is the R on T phenomenon 01:07:36.619 --> 01:07:40.139 leading to VF if the device fails to sense. The 01:07:40.139 --> 01:07:42.539 priority action is to check connections and increase 01:07:42.539 --> 01:07:45.280 the milliamps if there is no capture. And the 01:07:45.280 --> 01:07:48.260 treatment is repositioning the patient and interrogating 01:07:48.260 --> 01:07:52.719 the device. A patient with a temporary transvenous 01:07:52.719 --> 01:07:55.440 pacemaker suddenly becomes dizzy, and the monitor 01:07:55.440 --> 01:07:58.300 shows sharp pacer spikes marching right through 01:07:58.300 --> 01:08:01.380 their intrinsic QRS complexes without generating 01:08:01.380 --> 01:08:03.860 any new heartbeats. So if you see a pacer spike 01:08:03.860 --> 01:08:06.739 followed by a flat line instead of a QRS, think 01:08:06.739 --> 01:08:09.039 failure to capture and immediately increase the 01:08:09.039 --> 01:08:11.239 electrical milliamps on the generator. Spot on. 01:08:11.420 --> 01:08:13.960 Wow. We have been on a massive journey through 01:08:13.960 --> 01:08:16.359 the electrical grid of the heart today. We started 01:08:16.359 --> 01:08:18.579 by identifying the chaotic flickering lights 01:08:18.579 --> 01:08:21.170 and the stroke risks associated with atrial fibrillation. 01:08:21.210 --> 01:08:24.109 We covered a lot. We really did. We learned how 01:08:24.109 --> 01:08:26.890 to recognize the absolute severed wiring of a 01:08:26.890 --> 01:08:29.390 third degree heart block and we proved exactly 01:08:29.390 --> 01:08:31.850 why giving atropine in that scenario is a deadly 01:08:31.850 --> 01:08:34.859 pharmacological trap. We tackled the explosive 01:08:34.859 --> 01:08:38.000 power surges of ventricular tachycardia and fibrillation 01:08:38.000 --> 01:08:40.720 and broke down the vital physics of defibrillation 01:08:40.720 --> 01:08:43.739 versus cardioversion. We untangled the ultimate 01:08:43.739 --> 01:08:46.979 deception of PEA, where the monitor lies to you 01:08:46.979 --> 01:08:48.899 because the electrical panel is fine, but the 01:08:48.899 --> 01:08:52.060 plumbing pump is dry. And finally, we troubleshot 01:08:52.060 --> 01:08:54.100 the physical failures of the smart home devices 01:08:54.100 --> 01:08:57.000 we implant to try and fix all of this. It is 01:08:57.000 --> 01:08:58.880 an overwhelming amount of information if you 01:08:58.880 --> 01:09:01.899 try to just memorize it. but by aggressively 01:09:01.899 --> 01:09:04.579 applying that intensivist thinking. always tracing 01:09:04.579 --> 01:09:06.739 the problem down to the cellular physiology, 01:09:07.180 --> 01:09:09.079 identifying the immediate hemodynamic thread, 01:09:09.560 --> 01:09:11.939 implementing the targeted intervention, and reassessing 01:09:11.939 --> 01:09:14.680 it stops being a list of facts and becomes a 01:09:14.680 --> 01:09:17.159 logical, biological sequence. But before we finish, 01:09:17.500 --> 01:09:19.279 I want to leave you with a final provocative 01:09:19.279 --> 01:09:21.840 thought regarding the horizon of critical cardiac 01:09:21.840 --> 01:09:24.279 care. Oh, let's hear it. We just spent that last 01:09:24.279 --> 01:09:27.260 entire segment discussing how broken synthetic 01:09:27.260 --> 01:09:30.760 leads, dislodged wires, and dead batteries cause 01:09:30.760 --> 01:09:33.949 pacemakers to fail. The wires are the weakest 01:09:33.949 --> 01:09:36.590 link, but what if we completely eliminated them? 01:09:36.670 --> 01:09:40.829 Wait, like a wireless pacemaker? Yes. Yeah. We 01:09:40.829 --> 01:09:43.850 are currently entering the era of leadless permanent 01:09:43.850 --> 01:09:46.869 pacemakers. These are entirely self -contained 01:09:46.869 --> 01:09:49.989 tiny capsules about the size of a large vitamin 01:09:49.989 --> 01:09:52.909 pill. No way. Yeah, they are navigated up through 01:09:52.909 --> 01:09:55.449 the femoral vein and injected directly into the 01:09:55.449 --> 01:09:57.840 wall of the right ventricle. There are absolutely 01:09:57.840 --> 01:10:00.699 no wires attached and no generator pocket cut 01:10:00.699 --> 01:10:03.439 into the chest. That eliminates the risk of dislodging 01:10:03.439 --> 01:10:05.659 a lead by raising your arm and it eliminates 01:10:05.659 --> 01:10:08.279 the risk of pocket infections. Exactly, but it 01:10:08.279 --> 01:10:10.600 gets even more fascinating. Researchers are currently 01:10:10.600 --> 01:10:12.760 developing experimental devices that don't even 01:10:12.760 --> 01:10:14.720 use chemical batteries. Wait, how do they get 01:10:14.720 --> 01:10:17.399 power? They utilize piezoelectric materials to 01:10:17.399 --> 01:10:19.359 harvest kinetic energy directly from the physical 01:10:19.359 --> 01:10:21.869 motion of the heartbeat itself. The physical 01:10:21.869 --> 01:10:24.109 squeezing of the heart generates the micro voltage 01:10:24.109 --> 01:10:26.649 needed to power the microprocessor. So going 01:10:26.649 --> 01:10:29.369 back to our metaphor, the house of the future 01:10:29.369 --> 01:10:31.869 won't have fragile wires buried in the walls 01:10:31.869 --> 01:10:35.029 and it won't need a battery backup. The movement 01:10:35.029 --> 01:10:37.409 of the house itself will generate the electricity 01:10:37.409 --> 01:10:40.310 required to keep the grid online. The electrical 01:10:40.310 --> 01:10:43.229 grid will literally heal and power itself. That 01:10:43.229 --> 01:10:45.829 is incredible. It completely changes everything 01:10:45.829 --> 01:10:47.869 we know about troubleshooting these devices. 01:10:48.470 --> 01:10:50.869 The future of intensivist care is always evolving. 01:10:51.369 --> 01:10:53.289 Thank you all for joining us on this deep dive 01:10:53.289 --> 01:10:55.609 into the intensive care unit. Remember, whether 01:10:55.609 --> 01:10:58.670 you are managing a stable AFIV patient or running 01:10:58.670 --> 01:11:01.670 a chaotic code blue, stay curious, constantly 01:11:01.670 --> 01:11:04.310 rely on your cellular pathophysiology, and always, 01:11:04.310 --> 01:11:06.489 always treat the patient, not just the monitor.