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 try Jiminy so basically every second 00:20:37.450 --> 00:20:41.289 beat will be by Jiminy and then every third beat 00:20:41.289 --> 00:20:46.269 will be try Jiminy okay and now I think I am 00:20:46.269 --> 00:20:48.309 done when you look at a healthy city from above 00:20:48.309 --> 00:20:51.549 at night it's it's like a perfect network of 00:20:51.549 --> 00:20:54.109 light Everything is synchronized. Traffic lights 00:20:54.109 --> 00:20:56.630 change precisely when they need to. Power routes 00:20:56.630 --> 00:20:58.529 to the neighborhoods pulling the most current. 00:20:59.049 --> 00:21:01.490 And, you know, the whole grid just hums. Right. 00:21:01.569 --> 00:21:03.990 Yeah, it's totally balanced. Exactly. But if 00:21:03.990 --> 00:21:06.569 a main substation blows or like a rogue signal 00:21:06.569 --> 00:21:09.329 scrambles the system, the entire city goes dark 00:21:09.329 --> 00:21:11.690 in an instant. And that sudden darkness, you 00:21:11.690 --> 00:21:15.069 know, that catastrophic failure of the grid is 00:21:15.069 --> 00:21:17.750 exactly what we're looking at today. But inside 00:21:17.750 --> 00:21:20.900 the human chest. Because we aren't just here 00:21:20.900 --> 00:21:24.380 to memorize squiggly lines on an ECG paper. Today, 00:21:24.480 --> 00:21:28.079 we are taking a really dense clinical text on 00:21:28.079 --> 00:21:30.680 electrocardiographic monitoring and aggressively 00:21:30.680 --> 00:21:32.839 applying an intensivist filter for this deep 00:21:32.839 --> 00:21:35.160 dive. Yeah, we really are. If you are an ICU 00:21:35.160 --> 00:21:37.759 nurse standing at the bedside, your job isn't 00:21:37.759 --> 00:21:40.660 to react to the darkness. Your job is to anticipate 00:21:40.660 --> 00:21:42.819 the deterioration before the grid goes down. 00:21:42.970 --> 00:21:45.750 Exactly. I mean, critical care is about evaluating 00:21:45.750 --> 00:21:48.950 failing physiology in real time. You are constantly 00:21:48.950 --> 00:21:50.750 running this loop. Like, what is the mechanical 00:21:50.750 --> 00:21:53.170 problem? How is the physiology failing? What 00:21:53.170 --> 00:21:55.250 is the immediate threat to the patient's life? 00:21:55.349 --> 00:21:57.890 Right. And then what is my intervention? Thought 00:21:57.890 --> 00:22:00.769 on. And finally, the reassessment. So today, 00:22:00.809 --> 00:22:03.809 we are analyzing the highest yield, most dangerous 00:22:03.809 --> 00:22:06.390 cardiac dysrhythmias. We're breaking down exactly 00:22:06.390 --> 00:22:09.910 what will kill your patient first and the priority 00:22:09.910 --> 00:22:12.369 actions you have to take to stop it. We've got 00:22:12.369 --> 00:22:14.329 to start with the absolute worst case scenarios, 00:22:14.710 --> 00:22:17.410 like when the heart's grid just experiences a 00:22:17.410 --> 00:22:19.990 massive explosive system failure. We're talking 00:22:19.990 --> 00:22:23.329 about ventricular tachycardia, or VT, and ventricular 00:22:23.329 --> 00:22:26.049 fibrillation, VF. These are the lethal threats. 00:22:26.230 --> 00:22:28.910 I mean, to give you the 80 -20 breakdown, VT 00:22:28.910 --> 00:22:31.549 occurs when an ectopic focus, like a rogue cell 00:22:31.549 --> 00:22:34.089 in the ventricles, just completely hijacks the 00:22:34.089 --> 00:22:36.150 electrical system. It takes over. Yeah, it becomes 00:22:36.150 --> 00:22:38.609 the new pacemaker, firing at a massive rate, 00:22:38.609 --> 00:22:42.450 usually between 150 to 200. beats per minute, 00:22:42.809 --> 00:22:44.950 and then VF is the progression of that chaos. 00:22:45.089 --> 00:22:47.630 So it gets worse. Oh, much worse. Instead of 00:22:47.630 --> 00:22:50.710 one rogue cell, you have multiple ectopic foci 00:22:50.710 --> 00:22:53.309 firing all at once. The ventricles aren't even 00:22:53.309 --> 00:22:55.390 pumping anymore. They're just kind of quivering 00:22:55.390 --> 00:22:58.710 like a bag of worms. So mechanically, like at 00:22:58.710 --> 00:23:01.019 the bedside, How does that actually translate 00:23:01.019 --> 00:23:03.660 to the patient's physiology? I mean, if the heart 00:23:03.660 --> 00:23:05.839 is beating at 250 beats a minute, isn't it just 00:23:05.839 --> 00:23:08.240 pumping a ton of blood? That's a super common 00:23:08.240 --> 00:23:11.200 misconception actually, but it's the exact opposite. 00:23:11.599 --> 00:23:14.119 At that extreme rate, your diastolic filling 00:23:14.119 --> 00:23:16.960 time is functionally zero. Oh, wow. Right. The 00:23:16.960 --> 00:23:19.359 heart is beating so fast that it never has a 00:23:19.359 --> 00:23:21.500 fraction of a second to relax and fill with blood. 00:23:21.859 --> 00:23:24.720 So if you have no filling time, your stroke volume 00:23:24.720 --> 00:23:27.220 basically plummets to zero. And if your stroke 00:23:27.220 --> 00:23:29.859 volume is zero, your cardiac output is zero. 00:23:29.880 --> 00:23:32.920 Which means cardiopulmonary arrest, like zero 00:23:32.920 --> 00:23:35.940 oxygen delivery to the tissues. The brain and 00:23:35.940 --> 00:23:39.099 organs are actively dying. Precisely. The moment 00:23:39.099 --> 00:23:42.170 cardiac output drops to zero, you see this rapid 00:23:42.170 --> 00:23:44.710 clinical deterioration. Your patient becomes 00:23:44.710 --> 00:23:47.109 totally unresponsive, pulseless, and apneic. 00:23:47.230 --> 00:23:49.259 And what are we seeing on the monitor? On the 00:23:49.259 --> 00:23:53.279 ECG, VT looks like wide, distorted QRS complexes, 00:23:53.900 --> 00:23:57.259 so greater than 0 .12 seconds, marching out rapidly 00:23:57.259 --> 00:24:00.359 with absolutely no visible P waves. VF, on the 00:24:00.359 --> 00:24:02.599 other hand, just looks like chaotic, irregular 00:24:02.599 --> 00:24:05.440 waveforms of varying amplitude. There is no structure 00:24:05.440 --> 00:24:08.039 to it at all. OK, but how do we spot the spark 00:24:08.039 --> 00:24:10.859 before the explosion? The source material talks 00:24:10.859 --> 00:24:13.079 a lot about this trigger called the R -on -T 00:24:13.079 --> 00:24:14.839 phenomenon. It sounds like something hitting 00:24:14.839 --> 00:24:18.559 at the exact wrong microsecond. It is. T wave 00:24:18.559 --> 00:24:21.779 as the relative refractory period of ventricular 00:24:21.779 --> 00:24:24.740 repolarization. The reset phase. Exactly. The 00:24:24.740 --> 00:24:26.880 heart cells are resetting. And during that specific 00:24:26.880 --> 00:24:29.839 phase, they are incredibly unstable and highly 00:24:29.839 --> 00:24:32.900 excitable. If a premature ventricular contraction 00:24:32.900 --> 00:24:35.480 of PVC happens to fire and land perfectly on 00:24:35.480 --> 00:24:37.599 the peak of that T wave. It's like slamming a 00:24:37.599 --> 00:24:39.460 car into reverse while you're speeding 80 miles 00:24:39.460 --> 00:24:41.480 an hour down the highway. Just completely shred 00:24:41.480 --> 00:24:43.579 the engine. That is exactly what happens electrically. 00:24:43.700 --> 00:24:47.200 That single mistimed PVC throws the entire ventricular 00:24:47.180 --> 00:24:50.539 conduction system into lethal VT or VF. So if 00:24:50.539 --> 00:24:53.400 I'm at the bedside and I see this wide bizarre 00:24:53.400 --> 00:24:57.440 complex on the monitor My instinct is to immediately 00:24:57.440 --> 00:24:59.740 grab the defibrillator and shock them. Right. 00:24:59.920 --> 00:25:03.799 Stop right there. That instinct is like the number 00:25:03.799 --> 00:25:06.960 one trap that novice nurses fall into on exams 00:25:06.960 --> 00:25:10.099 and at the bedside. Wait, really? Yes. You always 00:25:10.099 --> 00:25:13.299 treat the patient, not the monitor. Your absolute 00:25:13.299 --> 00:25:16.059 first priority nursing action is to check the 00:25:16.059 --> 00:25:18.299 patient's responsiveness and check for a central 00:25:18.299 --> 00:25:21.720 pulse. But if the monitor shows VT, wouldn't 00:25:21.720 --> 00:25:24.140 they automatically be pulseless? Not always. 00:25:24.660 --> 00:25:27.200 A patient can have stable ventricular tachycardia. 00:25:27.279 --> 00:25:29.140 They might be sitting up talking to you with 00:25:29.140 --> 00:25:31.680 a palpable pulse, even though the monitor shows 00:25:31.680 --> 00:25:34.099 VT. Oh. Yeah. And if you take the defibrillator 00:25:34.099 --> 00:25:36.640 and deliver an unsynchronized shock to a stable 00:25:36.640 --> 00:25:38.740 patient with a pulse, you could actually cause 00:25:38.740 --> 00:25:41.019 the RNT phenomenon we just talked about, and 00:25:41.019 --> 00:25:43.220 literally push them right into lethal ventricular 00:25:43.220 --> 00:25:45.920 fibrillation. Wow. OK, so that completely changed 00:25:45.920 --> 00:25:48.700 the ADPIE protocol. If they are stable and talking, 00:25:49.059 --> 00:25:50.839 we're looking at synchronized cardioversion. 00:25:50.670 --> 00:25:53.930 or IV antirevimix. But if I check that pulse 00:25:53.930 --> 00:25:56.910 and there's nothing, like they're unresponsive 00:25:56.910 --> 00:25:59.910 and apneic, then what's the escalation? Then 00:25:59.910 --> 00:26:03.210 you escalate instantly. Call the code. Next, 00:26:03.269 --> 00:26:05.789 you start high quality CPR to mechanically force 00:26:05.789 --> 00:26:09.029 blood to the brain. Then you perform rapid defibrillation 00:26:09.029 --> 00:26:11.309 within two minutes. And defibrillation is just 00:26:11.309 --> 00:26:14.490 a massive wave of electricity, like 360 joules 00:26:14.490 --> 00:26:19.089 for monophasic monitors or 120 to 200 for biphasic. 00:26:19.500 --> 00:26:21.859 But what is that electricity actually doing? 00:26:22.000 --> 00:26:24.099 Are we restarting the heart? We aren't restarting 00:26:24.099 --> 00:26:26.579 it, no. We are momentarily stopping it. Stopping 00:26:26.579 --> 00:26:30.220 it. Yeah. The shock depolarizes the entire myocardium 00:26:30.220 --> 00:26:33.140 all at once. It wipes the slate clean. It stops 00:26:33.140 --> 00:26:35.720 all those chaotic ectopic foci in their tracks 00:26:35.720 --> 00:26:37.880 with the hope that the sinus node, the natural 00:26:37.880 --> 00:26:40.559 pacemaker, can wake up, reboot, and regain control 00:26:40.559 --> 00:26:44.140 of the grid. So while we are doing CPR and shocking, 00:26:44.980 --> 00:26:47.400 what are the primary meds we are pushing to fix 00:26:47.400 --> 00:26:49.900 the underlying physiology? We use epinephrine 00:26:49.900 --> 00:26:52.480 first. It's a potent alpha adrenergic agonist. 00:26:52.500 --> 00:26:54.980 So a vasopril. Exactly. We aren't giving it to 00:26:54.980 --> 00:26:57.460 stimulate the heart. We are giving it to clamp 00:26:57.460 --> 00:27:00.839 down the peripheral blood vessels, skyrocketing 00:27:00.839 --> 00:27:03.539 the systemic vascular resistance so that whatever 00:27:03.539 --> 00:27:06.900 little blood we are moving with CPR gets shunted 00:27:06.900 --> 00:27:09.759 directly to the central circulation, you know, 00:27:09.859 --> 00:27:11.599 the heart and the brain. That makes total sense. 00:27:11.720 --> 00:27:13.640 And the source material mentions amiodarone as 00:27:13.640 --> 00:27:17.069 well. Yes, Amidron is our primary anti -arrhythmic 00:27:17.069 --> 00:27:20.150 here. It's a class 3 potassium channel blocker. 00:27:20.289 --> 00:27:22.690 And what's the mechanism there? It works by delaying 00:27:22.690 --> 00:27:25.450 repolarization and prolonging the action potential. 00:27:25.970 --> 00:27:28.769 Essentially, it calms down that highly irritable 00:27:28.769 --> 00:27:31.589 ventricular tissue, making it harder for those 00:27:31.589 --> 00:27:34.529 rogue ectopic cells to fire again once we shock 00:27:34.529 --> 00:27:36.710 the patient out of the rhythm. OK, so if I'm 00:27:36.710 --> 00:27:38.769 synthesizing this into a core -intensivist framework, 00:27:38.829 --> 00:27:40.470 and if you only remember five things about this, 00:27:40.589 --> 00:27:43.049 one, the core pathophysiology is the ventricles 00:27:43.049 --> 00:27:45.329 going rogue, destroying filling time and cardiac 00:27:45.329 --> 00:27:47.990 output. Two, the key assessment finding is an 00:27:47.990 --> 00:27:51.440 unresponsive, pulseless apneic patient. Three, 00:27:51.779 --> 00:27:54.019 the most dangerous complication is sudden cardiac 00:27:54.019 --> 00:27:57.599 death. Four, priority nursing action is immediate 00:27:57.599 --> 00:28:01.640 CPR and rapid defibrillation. And five, the most 00:28:01.640 --> 00:28:03.799 important treatment is shocking the heart to 00:28:03.799 --> 00:28:06.539 reset the SA node. You nailed it. So for the 00:28:06.539 --> 00:28:09.559 one -sentence clinical picture, it's a totally 00:28:09.559 --> 00:28:12.799 unresponsive patient with a chaotic or wide complex 00:28:12.799 --> 00:28:15.160 rhythm on the monitor. Got it. And if you see 00:28:15.160 --> 00:28:19.220 wide, bizarre QRS complexes and no pulse, think 00:28:19.220 --> 00:28:23.380 pulseless VT or VF and do immediate CPR and defibrillation. 00:28:23.539 --> 00:28:25.299 Perfect. So that's what happens when the ventricles 00:28:25.299 --> 00:28:28.279 basically explode. But let's shift to a completely 00:28:28.279 --> 00:28:30.559 different kind of grid failure. What happens 00:28:30.559 --> 00:28:33.240 when the main power lines just get entirely severed? 00:28:33.259 --> 00:28:35.180 Ah, you're talking about complete heart block 00:28:35.180 --> 00:28:39.079 or third degree AV block. If VT is an electrical 00:28:39.079 --> 00:28:42.440 explosion, this is a silent choke. The text describes 00:28:42.440 --> 00:28:45.440 this as complete AV dissociation. So the top 00:28:45.440 --> 00:28:46.880 of the heart and the bottom of the heart are 00:28:46.880 --> 00:28:48.880 entirely divorced from one another. Completely 00:28:48.880 --> 00:28:51.420 divorced, it's usually triggered by severe ischemic 00:28:51.420 --> 00:28:54.619 heart disease like an acute MI or drug toxicity 00:28:54.619 --> 00:28:57.220 from beta blockers or digoxin. So the physiology 00:28:57.220 --> 00:29:00.440 changes how? Well, the SA node up in the atria 00:29:00.440 --> 00:29:03.460 is firing perfectly fine, generating normal P 00:29:03.460 --> 00:29:06.700 waves at 60 to 100 beats per minute. But the 00:29:06.700 --> 00:29:09.019 AV node, which is the gateway to the ventricles, 00:29:09.339 --> 00:29:12.460 becomes a brick wall. absolutely no electrical 00:29:12.460 --> 00:29:14.980 impulses get through. Wait, if no impulses get 00:29:14.980 --> 00:29:17.019 through, how does the patient not just instantly 00:29:17.019 --> 00:29:19.980 flatline and die? Because the heart has backup 00:29:19.980 --> 00:29:22.380 generators. When the ventricles realize they 00:29:22.380 --> 00:29:24.759 aren't getting the signal, an escape pacemaker 00:29:24.759 --> 00:29:26.920 somewhere in the ventricular tissue wakes up 00:29:26.920 --> 00:29:28.839 and takes over. Oh, that's a clever compensation. 00:29:29.200 --> 00:29:31.559 It is, but here is the decompensation problem. 00:29:31.960 --> 00:29:34.279 The further down the conduction system you go, 00:29:34.400 --> 00:29:36.900 the slower the inherent rate. That ventricular 00:29:36.900 --> 00:29:39.680 escapism only fires at 20 to 60 beats per minute. 00:29:39.940 --> 00:29:42.819 20 to 60. So we're looking at profound bradycardia. 00:29:43.200 --> 00:29:45.539 The cardiac output must be tanking. Exactly. 00:29:45.700 --> 00:29:48.240 The patient is bradycardic, hypotensive, and 00:29:48.240 --> 00:29:50.859 severely hypoperfusing. Early on, they might 00:29:50.859 --> 00:29:53.220 just complain of extreme fatigue, but you know 00:29:53.220 --> 00:29:55.680 they are actively deteriorating if their mentation 00:29:55.680 --> 00:29:58.660 drops, their MAP plummets, or they experience 00:29:58.660 --> 00:30:02.160 syncope. On the ECG, how do we distinguish this 00:30:02.160 --> 00:30:04.500 from other blocks? I mean, I know there are second 00:30:04.500 --> 00:30:06.940 degree blocks where beats get dropped. Pattern 00:30:06.940 --> 00:30:09.400 recognition is key here. In second degree type 00:30:09.400 --> 00:30:13.539 one, or Benkebock, the PR interval gets progressively 00:30:13.539 --> 00:30:16.339 longer until a beat drops. Longer, longer, longer 00:30:16.339 --> 00:30:19.279 drop. Right. In type two, the PR interval is 00:30:19.279 --> 00:30:21.940 constant, but you randomly drop QRS complexes. 00:30:22.299 --> 00:30:25.500 But in third degree, there is zero relationship. 00:30:25.690 --> 00:30:28.190 The P waves march out at their own regular rate. 00:30:28.569 --> 00:30:31.329 The QRS complexes march out at their own much 00:30:31.329 --> 00:30:34.430 slower regular rate. The PR intervals are completely 00:30:34.430 --> 00:30:36.650 chaotic because the atria and ventricles are 00:30:36.650 --> 00:30:38.210 total divorced. All right, so I've identified 00:30:38.210 --> 00:30:41.309 it on the monitor and the patient is like gray, 00:30:41.470 --> 00:30:43.750 confused, and their blood pressure is crashing. 00:30:43.950 --> 00:30:46.529 What is the priority nursing action? I know atropine 00:30:46.529 --> 00:30:49.470 is the standard ACLS drug for symptomatic bradycardia. 00:30:49.750 --> 00:30:51.670 Do we just push atropine to speed up the heart? 00:30:51.829 --> 00:30:54.970 No, and this is a massive exam trap and a crucial 00:30:54.990 --> 00:30:57.869 bedside pearl. Think about the pathophysiology. 00:30:58.950 --> 00:31:01.029 Atropine works by blocking vagal stimulation, 00:31:01.309 --> 00:31:03.630 which speeds up the SA node in the atria. But 00:31:03.630 --> 00:31:05.769 in third degree block, the pathway is physically 00:31:05.769 --> 00:31:08.829 severed at the AV node. Oh, so if you push atropine, 00:31:09.069 --> 00:31:10.789 you are just making the top of the heartbeat 00:31:10.789 --> 00:31:13.500 faster. but that signal is still hitting a brick 00:31:13.500 --> 00:31:15.680 wall. Exactly. It's like standing on one side 00:31:15.680 --> 00:31:17.859 of a canyon where the bridge is out and screaming 00:31:17.859 --> 00:31:20.099 at a stopped train on the other side to move. 00:31:20.579 --> 00:31:22.779 It does absolutely nothing for the ventricles. 00:31:23.160 --> 00:31:25.220 Atropine is useless here. So we have to pace 00:31:25.220 --> 00:31:27.640 them mechanically instead. Right. First priority. 00:31:28.099 --> 00:31:30.940 Apply transcutaneous pacemaker pads, TCP, to 00:31:30.940 --> 00:31:34.640 the anterior and posterior chest. Next, you set 00:31:34.640 --> 00:31:36.900 the pacing rate and the voltage on the external 00:31:36.900 --> 00:31:39.799 generator. Your goal is to achieve ventricular 00:31:39.799 --> 00:31:42.269 capture. Capture meaning the electricity from 00:31:42.269 --> 00:31:44.269 the pads is actually successfully triggering 00:31:44.269 --> 00:31:46.809 the heart muscle to squeeze. Yes. On the monitor, 00:31:46.809 --> 00:31:49.509 you will see a sharp pacemaker spike immediately 00:31:49.509 --> 00:31:52.750 followed by a wide QRS complex. And mechanically, 00:31:52.809 --> 00:31:55.509 you must confirm capture by feeling for a corresponding 00:31:55.509 --> 00:31:58.910 mechanical pulse. But wait, transcutaneous pacing 00:31:58.910 --> 00:32:01.609 means we are shooting enough external electrical 00:32:01.609 --> 00:32:04.549 current through the skin, fat, and skeletal muscle 00:32:04.549 --> 00:32:07.009 of the chest wall to force the heart to beat. 00:32:07.349 --> 00:32:09.529 That has to be brutally painful for the patient. 00:32:09.710 --> 00:32:13.470 Oh, it is agonizing. The current causes the chest 00:32:13.470 --> 00:32:16.150 muscles to twitch forcefully with every single 00:32:16.150 --> 00:32:19.410 beat. So an independent and vital nursing action, 00:32:19.769 --> 00:32:21.470 assuming the patient is conscious and has an 00:32:21.470 --> 00:32:24.789 airway, is providing immediate analgesia and 00:32:24.789 --> 00:32:27.680 sedation. And TCP is just a temporary bridge, 00:32:27.859 --> 00:32:30.359 right? Yes, exactly. While you are pacing them 00:32:30.359 --> 00:32:33.440 externally, you might hang a dopamine or epinephrine 00:32:33.440 --> 00:32:35.599 drip to temporarily support the blood pressure. 00:32:36.059 --> 00:32:38.579 But the definitive treatment, the THIDA -N in 00:32:38.579 --> 00:32:40.940 your priority list, is preparing the patient 00:32:40.940 --> 00:32:43.220 for the insertion of a temporary transvenous 00:32:43.220 --> 00:32:45.700 or a permanent pacemaker. Okay, pulling this 00:32:45.700 --> 00:32:47.279 all together for the five things to remember. 00:32:47.450 --> 00:32:50.289 One, core pathophysiology is complete failure 00:32:50.289 --> 00:32:52.509 of AV conduction, so atria and ventricles beat 00:32:52.509 --> 00:32:56.309 independently. Two, key assessment is profound 00:32:56.309 --> 00:32:58.650 bradycardia with signs of hypoperfusion, like 00:32:58.650 --> 00:33:02.109 shock or syncope. Three, most dangerous complication 00:33:02.109 --> 00:33:04.710 is periods of a systole and cardiovascular collapse. 00:33:04.769 --> 00:33:07.430 Thought on. Four, priority nursing action is 00:33:07.430 --> 00:33:10.150 initiating transcutaneous pacing. And five, the 00:33:10.150 --> 00:33:12.190 most important treatment is permanent pacemaker 00:33:12.190 --> 00:33:14.519 insertion. Perfect. So the one sentence clinical 00:33:14.519 --> 00:33:18.160 picture here. A patient with profound symptomatic 00:33:18.160 --> 00:33:20.900 bradycardia where the ECG shows regular P waves 00:33:20.900 --> 00:33:23.940 and regular QRS complexes that march out completely 00:33:23.940 --> 00:33:26.240 independently of one another. And the rule of 00:33:26.240 --> 00:33:28.779 thumb. If you see totally dissociated P waves 00:33:28.779 --> 00:33:31.519 and QRS complexes with hypotension, think complete 00:33:31.519 --> 00:33:34.660 heart block and do transcutaneous pacing immediately. 00:33:34.779 --> 00:33:36.900 That is exactly how an intensivist approaches 00:33:36.900 --> 00:33:39.319 it. Now we've covered the bottom of the hard 00:33:39.319 --> 00:33:41.779 going rogue and the connections being severed. 00:33:42.079 --> 00:33:44.279 Let's move above the ventricles to our final 00:33:44.279 --> 00:33:47.940 topic, the REIT race. We are looking at atrial 00:33:47.940 --> 00:33:50.920 fibrillation and paroxysmal superventricular 00:33:50.920 --> 00:33:54.740 tachycardia, or PSVT. Right, these are superventricular, 00:33:54.839 --> 00:33:57.180 meaning the chaotic electrical activity originates 00:33:57.180 --> 00:33:59.500 above the bundle of his. But if the problem is 00:33:59.500 --> 00:34:01.400 in the top of the heart, why is it so dangerous 00:34:01.400 --> 00:34:03.619 for the whole system? It all comes back to how 00:34:03.619 --> 00:34:06.160 the atrial behavior impacts the ventricles and 00:34:06.160 --> 00:34:09.230 ultimately cardiac output. Let's look at PSVT 00:34:09.230 --> 00:34:12.090 first. This is usually caused by a reentrant 00:34:12.090 --> 00:34:14.650 loop like a short circuit that traps the electrical 00:34:14.650 --> 00:34:16.929 signal in a continuous rapid circle. And what's 00:34:16.929 --> 00:34:20.210 the rate? It causes abrupt extreme heart rates 00:34:20.210 --> 00:34:24.550 of 150 to 220 beats per minute. Ah, so we are 00:34:24.550 --> 00:34:27.309 back to the diastolic filling problem. Even though 00:34:27.309 --> 00:34:29.909 the signal originates in the atria, a rate of 00:34:29.909 --> 00:34:32.869 200 beats a minute drastically cuts into the 00:34:32.869 --> 00:34:36.050 ventricular relaxation time. Stroke volume drops, 00:34:36.530 --> 00:34:39.630 causing profound hypotension and ischemia. Exactly. 00:34:40.190 --> 00:34:42.489 But atrial fibrillation presents a different 00:34:42.489 --> 00:34:45.929 mechanical problem. In AFib, there are ectopic 00:34:45.929 --> 00:34:49.329 foci all over the atria firing chaotically, usually 00:34:49.329 --> 00:34:53.449 between 350 to 600 times a minute. 600. How do 00:34:53.449 --> 00:34:56.469 the ventricles not just match that rate and literally 00:34:56.469 --> 00:34:59.840 explode? Thankfully, the AV node acts as a gatekeeper. 00:34:59.960 --> 00:35:03.059 It won't let all 600 impulses through. But because 00:35:03.059 --> 00:35:05.739 the atria are firing so chaotically, they aren't 00:35:05.739 --> 00:35:07.920 actually contracting. They are just quivering. 00:35:08.199 --> 00:35:10.820 So they lose their squeeze. Right. When you lose 00:35:10.820 --> 00:35:13.059 that synchronized atrial contraction, you lose 00:35:13.059 --> 00:35:15.760 what we call the atrial kick, that final coordinated 00:35:15.760 --> 00:35:17.980 squeeze of blood down into the ventricles right 00:35:17.980 --> 00:35:20.000 before they pump. And how much does that actually 00:35:20.000 --> 00:35:22.579 matter for the patient's perfusion? Losing the 00:35:22.579 --> 00:35:24.820 atrial kick drops your overall cardiac output 00:35:24.820 --> 00:35:27.860 by 20 to 30 percent. Wow. Yeah, if your patient 00:35:27.860 --> 00:35:30.199 already has a compromised heart, that sudden 00:35:30.199 --> 00:35:32.380 drop in perfusion can throw them right into heart 00:35:32.380 --> 00:35:35.179 failure. So on the monitor, what's the distinguishing 00:35:35.179 --> 00:35:38.960 pattern between the two? Well, PSVT is a regular, 00:35:39.320 --> 00:35:43.400 rapid, narrow, complex tachycardia. It's so fast 00:35:43.400 --> 00:35:45.679 that the P wave is usually buried inside the 00:35:45.679 --> 00:35:48.820 preceding T wave. And AFib. AFib is classically 00:35:48.820 --> 00:35:51.300 described as an irregularly irregularly irregularly 00:35:51.300 --> 00:35:51.300 irregularly irregularly irregularly irregularly 00:35:51.300 --> 00:35:51.300 irregularly irregularly irregularly irregularly 00:35:51.300 --> 00:35:51.340 irregularly irregularly irregularly irregularly 00:35:51.340 --> 00:35:51.340 irregularly irregularly irregularly irregularly 00:35:51.340 --> 00:35:51.340 irregularly irregularly irregularly irregularly 00:35:51.340 --> 00:35:51.340 irregularly irregularly irregularly irregularly 00:35:51.340 --> 00:35:51.400 irregularly irregularly irregularly irregularly 00:35:51.400 --> 00:35:51.400 irregularly irregularly irregularly irregularly 00:35:51.400 --> 00:35:51.400 irregularly irregularly irregularly irregularly 00:35:51.400 --> 00:35:51.400 irregularly irregularly irregularly irregularly 00:35:51.400 --> 00:35:51.400 irregularly irregularly irregularly irregularly 00:35:51.400 --> 00:35:51.400 irregularly irregularly irregularly irregularly 00:35:51.400 --> 00:35:51.400 irregularly irregularly irregularly irregularly 00:35:51.400 --> 00:35:52.619 irregularly irregularly irregular rhythm. The 00:35:52.619 --> 00:35:55.019 QRS complexes are narrow, but the distance between 00:35:55.019 --> 00:35:58.360 them is completely random. And there are no distinct 00:35:58.360 --> 00:36:01.380 P waves at all, just a chaotic, fibrillatory 00:36:01.380 --> 00:36:03.340 baseline. OK, let's talk interventions, because 00:36:03.340 --> 00:36:05.340 I know they differ drastically. Start with AFib. 00:36:05.760 --> 00:36:08.480 If the AV node is letting too many beats through, 00:36:09.179 --> 00:36:11.420 say, a ventricular rate of 130, our priority 00:36:11.420 --> 00:36:13.780 is rate control, right? We need to slow down 00:36:13.780 --> 00:36:16.619 that AV node conduction. Yes. We use medications 00:36:16.619 --> 00:36:19.159 like Diltiazem, which is a calcium channel blocker, 00:36:19.159 --> 00:36:21.800 or Metaprolol, a beta blocker. But AFib has... 00:36:21.670 --> 00:36:24.550 a unique massive complication that you must assess 00:36:24.550 --> 00:36:26.849 for before you try to convert them back to a 00:36:26.849 --> 00:36:29.750 normal sinus rhythm. The plot risk. Because the 00:36:29.750 --> 00:36:31.690 atria are just quivering, the blood isn't being 00:36:31.690 --> 00:36:33.989 efficiently inked in. It gets stagnant, especially 00:36:33.989 --> 00:36:36.630 in that small anatomical pouch called the left 00:36:36.630 --> 00:36:39.809 atrial appendage. Exactly. Blood stasis leads 00:36:39.809 --> 00:36:43.400 to thrombi. If a patient has been in AFib for 00:36:43.400 --> 00:36:46.179 more than 48 hours, you have to assume they have 00:36:46.179 --> 00:36:49.300 a clot in their heart. If you just shock them, 00:36:49.480 --> 00:36:51.900 or give them a rhythm converting drug, and the 00:36:51.900 --> 00:36:55.300 atria suddenly give a strong, effective squeeze, 00:36:55.619 --> 00:36:58.099 you'll dislodge the clot, pump it right up the 00:36:58.099 --> 00:37:00.860 carotids, and cause a massive, embolic stroke. 00:37:01.159 --> 00:37:03.519 Precisely. So the nursing priority completely 00:37:03.519 --> 00:37:06.880 changes. If it's been over 48 hours, they require 00:37:06.880 --> 00:37:09.860 anticoagulation like warfarin or illiquis for 00:37:09.860 --> 00:37:12.199 three to four weeks before you can safely attempt 00:37:12.199 --> 00:37:14.599 cardioversion. Wow, three to four weeks. Yeah. 00:37:15.000 --> 00:37:18.079 The only exception is if you do a transesophageal 00:37:18.079 --> 00:37:20.599 echocardiogram right then and there to definitively 00:37:20.599 --> 00:37:23.260 prove there is no clot. That is a brilliant safety 00:37:23.260 --> 00:37:25.539 check to keep in mind. Okay, what about PSVT? 00:37:25.940 --> 00:37:28.159 The patient's heart is suddenly racing at 180 00:37:28.159 --> 00:37:31.030 beats a minute. They are feeling palpitations, 00:37:31.349 --> 00:37:34.449 chest pressure, and dyspnea. For PSVT, our actions 00:37:34.449 --> 00:37:37.530 are ranked. First, assuming they are stable, 00:37:37.889 --> 00:37:40.849 we try vagal maneuvers. We ask the patient to 00:37:40.849 --> 00:37:43.130 bear down as if they're having a bowel movement, 00:37:43.570 --> 00:37:45.809 the Valsalva maneuver. And that just stimulates 00:37:45.809 --> 00:37:49.449 the vagus nerve to naturally slow the AV node. 00:37:55.019 --> 00:37:58.179 deep into adenosine, and honestly, the mechanism 00:37:58.179 --> 00:38:01.880 sounds terrifying. It's described as a hard reboot 00:38:01.880 --> 00:38:04.420 for the heart. It absolutely is, and it can be 00:38:04.420 --> 00:38:06.780 terrifying for the patient. Adenosine briefly 00:38:06.780 --> 00:38:09.260 blocks conduction through the AV node entirely. 00:38:09.739 --> 00:38:11.880 When you push it, it effectively causes a brief 00:38:11.880 --> 00:38:14.659 period of complete assistal. So they just flatline? 00:38:14.820 --> 00:38:16.900 Yeah. The patient will flatline on the monitor 00:38:16.900 --> 00:38:19.139 for a few seconds before the SA node hopefully 00:38:19.139 --> 00:38:21.440 reasserts itself and takes over in a normal rhythm. 00:38:21.659 --> 00:38:24.179 You are intentionally flatlining them. So the 00:38:24.179 --> 00:38:26.119 independent nursing action here has to be massive 00:38:26.119 --> 00:38:28.119 patient education. You have to warn them that 00:38:28.119 --> 00:38:29.980 they're going to feel a sudden, intense wave 00:38:29.980 --> 00:38:32.199 of chest pressure and a feeling of impending 00:38:32.199 --> 00:38:35.199 doom. Yes, you must explain that it will feel 00:38:35.199 --> 00:38:38.400 terrible, but it will pass in seconds. And from 00:38:38.400 --> 00:38:40.960 a pharmacological standpoint, adenosine has a 00:38:40.960 --> 00:38:43.159 half -life of less than 10 seconds. So you have 00:38:43.159 --> 00:38:45.559 to push it fast. Extremely fast. If you push 00:38:45.559 --> 00:38:48.119 it slowly, the blood enzymes will chew it up 00:38:48.119 --> 00:38:50.380 before it ever reaches the heart. So it's a rapid 00:38:50.380 --> 00:38:53.559 IV push. One to two seconds, ideally through 00:38:53.559 --> 00:38:55.739 a stopcock on a line as close to the heart as 00:38:55.739 --> 00:38:59.059 possible, followed instantly by a rapid 20 -milliliter 00:38:59.059 --> 00:39:01.539 saline flush. elevate the arm to get it central. 00:39:01.860 --> 00:39:04.539 Exactly. But what if the adenosine fails, or 00:39:04.539 --> 00:39:07.940 what if the PSVT patient is hemodynamically unstable 00:39:07.940 --> 00:39:10.539 from the start like crashing blood pressure, 00:39:10.880 --> 00:39:12.739 altered mental status? Then we don't mess around 00:39:12.739 --> 00:39:15.599 with meds. We go straight to synchronized cardioversion. 00:39:15.920 --> 00:39:18.039 We are delivering a shock to convert the rhythm. 00:39:18.239 --> 00:39:20.280 But here is where we circle all the way back 00:39:20.280 --> 00:39:22.519 to the very beginning of our discussion. If you 00:39:22.519 --> 00:39:25.239 are doing a synchronized cardioversion, you must 00:39:25.239 --> 00:39:27.639 visually confirm that the sync button on the 00:39:27.639 --> 00:39:31.610 defibrillator is engaged. Why? Oh, because if 00:39:31.610 --> 00:39:34.309 the sync button is on, the machine reads the 00:39:34.309 --> 00:39:37.329 patient's ECG and times the delivery of the electrical 00:39:37.329 --> 00:39:39.869 shock to fall precisely on the R wave of the 00:39:39.869 --> 00:39:42.590 QRS complex. And if you forget to hit the sync 00:39:42.590 --> 00:39:44.869 button... Then it's just a blind defibrillation 00:39:44.869 --> 00:39:47.369 shock. And if that blind shock randomly lands 00:39:47.369 --> 00:39:50.090 on the T wave, that's the R on T phenomenon. 00:39:50.530 --> 00:39:52.889 You'll send the patient straight from PSVT into 00:39:52.889 --> 00:39:55.530 lethal ventricular fibrillation. Exactly. A simple 00:39:55.530 --> 00:39:57.710 missed button can kill your patient instantly. 00:39:57.929 --> 00:40:00.829 That is why understanding the underlying electrophysiology 00:40:00.829 --> 00:40:03.670 is critical. So synthesizing this supraventricular 00:40:03.670 --> 00:40:06.909 section into the five things to remember. One, 00:40:07.269 --> 00:40:09.630 corpathal is extreme atrial rates, destroying 00:40:09.630 --> 00:40:12.769 diastolic filling time in PSVT or causing blood 00:40:12.769 --> 00:40:16.170 stasis in AFib. Right. Two, key assessment is 00:40:16.170 --> 00:40:19.579 an irregular irregular rhythm for AFib, or an 00:40:19.579 --> 00:40:22.840 abrupt extreme cacocardia for PSVT. Three, most 00:40:22.840 --> 00:40:25.079 dangerous complication is embolic stroke for 00:40:25.079 --> 00:40:28.420 AFib or severe hypotension for PSVT. Exactly. 00:40:28.539 --> 00:40:30.380 Four, priority nursing action is to control the 00:40:30.380 --> 00:40:32.719 ventricular rate and assess for hemodynamic instability. 00:40:33.199 --> 00:40:35.760 And five, most important treatment is adenosine 00:40:35.760 --> 00:40:39.199 for PSVT, rate controlling drugs, and anticoagulation 00:40:39.199 --> 00:40:41.420 for AFib. Perfect, so the one -sentence clinical 00:40:41.420 --> 00:40:44.400 picture for PSVT. A patient experiencing palpitations 00:40:44.400 --> 00:40:47.179 and dyspnea with a regular heart rate of 180 00:40:47.179 --> 00:40:49.820 beats per minute. And the rule. If you see a 00:40:49.820 --> 00:40:52.460 sudden, regular, narrow, complex tachycardia 00:40:52.460 --> 00:40:56.139 at 180, think PSVT and do vagal maneuvers or 00:40:56.139 --> 00:41:00.250 push adenosine. And for AFib, if you see an irregularly 00:41:00.250 --> 00:41:03.170 irregular rhythm with no P waves, think AFib 00:41:03.170 --> 00:41:05.750 and prioritize rate control and stroke prevention. 00:41:06.329 --> 00:41:09.190 That encapsulates the entire intensivist mindset 00:41:09.190 --> 00:41:11.230 we've been talking about. You aren't just reacting 00:41:11.230 --> 00:41:14.250 to alarms, you're evaluating the failing physiology 00:41:14.250 --> 00:41:17.539 at a cellular and mechanical level. You understand 00:41:17.539 --> 00:41:20.039 why losing atrial kit compromises perfusion, 00:41:20.460 --> 00:41:22.699 why a severed AV node makes atropine useless, 00:41:23.219 --> 00:41:25.659 and why a mistimed shock causes sudden death. 00:41:25.760 --> 00:41:27.679 You are anticipating the bottlenecks in the grid 00:41:27.679 --> 00:41:30.000 before the lights go out. It changes entirely 00:41:30.000 --> 00:41:32.219 how you look at the patient. But as we wrap up, 00:41:32.340 --> 00:41:34.139 there's a fascinating detail in the source material 00:41:34.139 --> 00:41:36.599 about the future of this grid management. We 00:41:36.599 --> 00:41:38.420 talked earlier about pacing patients with third 00:41:38.420 --> 00:41:41.099 degree block and the eventual need for a permanent 00:41:41.099 --> 00:41:43.940 transvenous pacemaker. But those wires, those 00:41:43.940 --> 00:41:46.139 leads, come with massive complications. They 00:41:46.139 --> 00:41:49.059 do, yeah. Transvenous leads run directly through 00:41:49.059 --> 00:41:51.320 the blood vessels into the heart. Over time, 00:41:51.480 --> 00:41:53.300 those wires can fracture, the insulation can 00:41:53.300 --> 00:41:56.119 break down, or they can become highways for severe 00:41:56.119 --> 00:41:59.420 systemic infections like endocarditis. But the 00:41:59.420 --> 00:42:01.480 text mentions a future where we eliminate the 00:42:01.480 --> 00:42:05.440 wires completely. Leadless. Battery -free pacemakers. 00:42:05.699 --> 00:42:08.539 Yes. The engineering is incredible. We are looking 00:42:08.539 --> 00:42:11.940 at a future where a tiny receiver, like a seed, 00:42:12.420 --> 00:42:14.780 is placed directly into the cardiac chamber tissue. 00:42:15.139 --> 00:42:17.300 There are no batteries or wires inside the heart. 00:42:17.420 --> 00:42:19.880 So how does it work? An external transmitter 00:42:19.880 --> 00:42:22.920 beams ultrasound energy right through the patient's 00:42:22.920 --> 00:42:25.860 chest tissue. That little seed captures the acoustic 00:42:25.860 --> 00:42:28.139 energy and converts it into the electrical pacing 00:42:28.139 --> 00:42:30.719 pulse that stimulates the muscle. Beaming sound 00:42:30.719 --> 00:42:32.960 waves to power a heart. That is just mind blowing. 00:42:33.119 --> 00:42:35.460 It raises some profound clinical questions for 00:42:35.460 --> 00:42:37.920 you to mull over. I mean, if we completely remove 00:42:37.920 --> 00:42:39.820 intravenous leads from the equation, how will 00:42:39.820 --> 00:42:42.099 that alter the landscape of ICU complications? 00:42:42.639 --> 00:42:45.320 How will it redefine cardiac resynchronization 00:42:45.320 --> 00:42:48.079 therapy for our most vulnerable in infection 00:42:48.079 --> 00:43:04.510 -prone, heart failure patients. behind every 00:43:04.510 --> 00:43:06.949 intervention, every medication mechanism, and 00:43:06.949 --> 00:43:09.449 every subtle change in the vital trends. Because 00:43:09.449 --> 00:43:12.050 anticipating the deterioration is exactly how 00:43:12.050 --> 00:43:13.650 you save a life. Though the next time you look 00:43:13.650 --> 00:43:15.690 up at that monitor, don't just see jagged white 00:43:15.690 --> 00:43:18.409 lines. Look for the flow of energy. Look for 00:43:18.409 --> 00:43:21.210 the failing physiology. Be the one who understands 00:43:21.210 --> 00:43:23.690 exactly how to keep the city's lights on when 00:43:23.690 --> 00:43:26.469 the grid starts to fail. Thanks for joining us 00:43:26.469 --> 00:43:27.289 on this deep dive.