hello and welcome to chapter 17 cardiovascular emergencies and this is part three if you remember in part one we went over the anatomy and physiology in part two we covered a lot about the ecg components and so part three we're going to discuss dysrhythmias interpretation and um the different treatments of the dysrhythmias okay so let's get started okay so when you're talking about dysrhythmias there is an approach to interpreting them and there's a method and when you look at the ecg strips you're going to be on alert for specific things and you're going to go in a specific order and so first you're going to identify the waves so you want to look at the p q r s and t waves and they you want to measure the p r i interval i'm going to measure the q restoration determine the rhythm regularity measure the heart rate okay so we're going to notation of whether the p waves are upright and fall within normal parameters so let's start talking about this so when it comes to the red rhythm regularity you want to determine whether it's regular and it can be done by simply measuring the distance between those r waves so when the rhythm is regular it's if the distance between the r waves are exactly the same and so you can see that on the slide you have a regular rhythm okay but remember on the last slide i said you could have any regular rhythm but it goes even more in depth you can have an irregularly irregular rhythm and that is when no two r waves are equal and then you could also have a regularly irregular rhythm and that's if the r waves are irregular but they appear to follow a pattern and so in the first one you could see it's an irregularly irregular rhythm second one there is in there there is regular irregularity okay when you determine the heart rate use the six second method and so this strip that you're going to see on the screen that is a six second strip the fastest method for measuring a heart rate is from the ecg on a six second strip and so what you could do is this can be used on regular any regular rhythms you want to count the number of qrs complexes in a six second strip and then you're going to multiply it by 10 to obtain the heart rate and so if you look on this strip you see one two three four five and you could multiply that by 10 and so you have a heart rate of 50. okay so there's the sequence method it's reserved for regular rhythms and so what you could do is memorize the following numbers you can 300 150 100 75 60 and 50. you find the r wave on the heavy line and count off the above sequence for each large box you land on until you reach the next r wave so if the rnr interval spans fewer than three large boxes the rate is greater than 100 and that of course is tachycardia if it is more than five large boxes then the rate is less than 60 and of course that's bradycardia the 1500 method is the most accurate typically used for heart rate that exceeds 150 and can only be used on regular rhythms count the number of small boxes between the two qrs complexes and of course the two qrs complexes we're talking about the rnr interval and then divide it by 1500 okay so if you have 23 small boxes you then you divide that by 1500 you're gonna get 153 for the heart rhythm great all right so specific cardiac dysrhythmias so cardiac dysrhythmias can be induced by many events the flow of electricity through damaged or oxygen deprived tissue is different than healthy tissue which may appear on ecg as irregularities many can be traced to ischemia especially the cardiac conduction system ischemia often causes spontaneous depolarization generating a premature complex that may interfere with multiple impulse conduction and induced dysrhythmias many dysrhythmias cause no serious symptoms so it's difficult to estimate the number of people affected dysrhythmias are the most common cause of a cardiac arrest and dysrhythmias are classified in numerous ways you have disturbances of the automaticity or disturbances of the conduction and rhythms that are too fast which are tachydysrhythmias or too slow which are brady dysrhythmias life-threatening or non-life-threatening and by the site from which they arise some rhythms originate in the sa node so of course we have the normal sinus rhythm and this arises in the sa node with an ischemic rate of 60 to 100 beats per minute with a regular rhythm and minimum variations between the rr intervals the p waves are upright and it precedes each qrs complex so the pri interval is point to 0.20 seconds and the qrs is 0.11 seconds or less you have sinus bradycardia and that's next the pacemaker is still in the sinus node but it's a rate of less than 60. and the upright p wave precedes every qrs still so the pr is still interval is 0.12 to 0.2 0 seconds and the qrs is 0.11 seconds so it's a very slow heart rate leading to an adequate co and precipitates heart electricity instability so etopic pacemakers in the av junction or ventricles may start to fire and produce escape beats when the sinus rate becomes too slow so in healthy adults and conditioned athletes sinus bradycardia may be asymptomatic but may occur during sleep and other adult sinus bradycardia may cause altered mental status ischemic chest discomfort acute heart failure and hypotension treatment is indicated when the signs and symptoms persist despite adequate oxygen and breathing okay so management of symptomatic bradycardia so the goals for management of emergency care include adequate oxygenation ventilation and perfusion correct the rhythm disturbance and restore a stable perfusing rhythm so searching for the underlying cause which may be hypoxia hypothermia shock altered mental status av block toxin exposure and so also an electrolyte disorder or increased intracranial pressure or other factors um so we want to the emergency care that we want to administer is we want to maintain that open airway you're going to assist breathing as necessary and administer supplemental oxygen as needed to maintain an spo2 of 90 or higher apply the cardiac monitor blood pressure monitor and pulse ox and maintain or obtain a 12 lead but do not delay emergency care establish an iv infusion of normal saline obtain a finger stuck blood glucose level and treat hypoglycemia administer atropine iv bolus for symptomatic bradycardia or a condition block conduction block at the level of the av node and repeat atropine every three to five minutes until the desired heart rate is achieved usually 60 beats per minute or faster or until the dosage limit of three milligrams has been reached if atropine is ineffective and the patient's symptoms or hemodynamic instability persist then consider transcutaneous pacing or the administration of dopamine or epi infusion transport the patient for definitive care this figure shows the recommended treatment guidelines for adult bradycardia with a pulse algorithm okay so next we're going to talk about artificial pacemakers they deliver repetitive bursts of electrical impulses to the heart and artificial pacemakers current can depolarize the myocardial tissue and substitute for a blocked non-functional natural pacemaker transcutaneous pacemaker transcutaneous pacemakers depolarize the myocardium by delivering electrical energy through the skin of the chest a small electrical charge passes through the patient's skin between one external pacemaker pad and another the energy increases until the heart begins to react to the stimulus this response called capture is usually associated with ventricular depolarization it's characterized by a wide qrs complex on the ecg and should result in a corresponding pulse okay so use of t cp in the following situation so a patient with bradycardic dysrhythmia that severely reduces co and does not respond to atropine a symptomatic patient with an artificial pacemaker failure so to properly initiate tcp refer to skill drill 17-2 okay next rhythm we're going to talk about is the sinus stack and that is a rhythm that originates in the sa node as well the sa node is still the pacemaker but the rate is between 101 and 180 beats per minute it's a regular rhythm a bright p wave precedes every qrs complex and the pr in a pri interval is 0.12 to 0.20 seconds and the qrs complex is 0.11 seconds or less sinus attack may result from various cases including pain fever hypoxia hypovolemia exercise stimulation of the sympathetic nervous system certain drugs caffeine nicotine or alcohol hypoxia metabolic alkalosis hypokalemia and hypocalcemia can lead to electrical instability prompting the firing of cells that normally do not generate impulses treatment is related to the underlying cause now we're going to talk about sinus dysrhythmia this is a slight variation in the cycling of the sinus rhythm usually exceeding 0.12 seconds between the longest and shortest cycles associated with respiratory cycle fluctuations the rate increases during inspiration and decreases during expiration the sa node is still the pacemaker and an upright p wave precedes every qrs complex sinus dysrhythmia is often found in children and young adults and tends to diminish with age now we're going to talk about sinus arrests this is still a rhythm originating in the sa node the sa node fails to initiate an impulse which eliminates the p wave qrs complex and or the t wave from one cardiac cycle then resumes normal functioning the atrial and ventricular rates are usually within normal limits when regular rhythm except for the absence of the complexes there's an upright p wave and they precede every qrs possible causes include ischemia of the sa node increased vagal tone or carotid sinus massage occasional episodes are not significant unless the heart rate drops below 60 beats a minute treatment may include a temporary pacemaker in the field or a permanent pacemaker placed once in the hospital sick sinus syndrome and that's a syndrome and is a variety of rhythms involving a poorly functioning sa node common in older adults patients may exhibit syncope dizziness palpations or may have other symptoms it shows on the ekg as sinus bradycardia sinus arrest and sa block or alternating patterns of extreme bradycardia and tachycardia okay so rhythms originating in the atria there are impulses from an area in the atria so upright p waves preceding each qrs and complex and some rhythms generated from the atria produce upright p waves preceding each qrs but they are not all as well rounded as those generated from the sa node premature atrial complexes so not technically a dysrhythmia but an atopic complex within another rhythm the premature atrial complex occurs earlier than the next expected complex which produces an abnormally r on r interval between it and in the previous complex causing an irregular rhythm an upright p wave precedes each qrs but its difference it differs from the p wave originating in the sa node so pacs are not always conducted to the ventricles a non-conducted pac is the presence of a p wave that occurs early on the ecg and is not followed by qrs do not confuse it with an av block pacs occur infrequently and have no particular pattern the p wave will be shorter in the p and p intervals pac is very common and can be caused by stress stimulants or other conditions and when pacs are frequent treatment is focused on correcting the underlying cause so let's talk about supraventricular tachycardia or svt next svt is a rhythm originating from the site above the ventricles svt is a ventricular rate faster than 100 beats at rest in patients with normal ventricular functioning tachycardia with the rate of less than 150 beats rarely causes sewer signs and symptoms the ventricular filling time is greatly lowered when the ventricular rate exceeds 150 beads when the ventricular rate reaches 150 to 180 beats per minute the p waves if present with the svg tend to be completely obscured by the t wave of the preceding beat the most common type of svt is called av nodal reentrant tachycardia it's associated with re-entry which is the spread of then impulse through the tissue already stimulated by the same impulse another conditions like the presence of myocardial ischemia a premature impulse can trigger a series of rapid beats these impulses could get stuck in a repetitive pattern generating multiple atopic beats in a very rapid rhythm patients sometimes have a physical finding known as cannon a-waves created when a disassociation between the atrium and the ventricle occurs and can indicate deteriorating functionality of the right ventricle or increasing right ventricular and diastolic pressure treatment depends on the severity of the patient's symptoms and may include medication or electrical therapy to slow the heart rate down this figure shows the process of reentry the spread of the impulse through the tissue that's already been stimulated note the following for the management of tachycardia with the pulse tachycardia is more complicated situation than bradycardia so tachycardia can originate from it from a supraventricular pacemaker site narrow qrs complexes a ventricular origin with wide qrs complexes in most cases the rhythm is ventricular and should be treated accordingly goals for emergency medical care include maintain the oxygenation ventilation and perfusion correct the rhythm disturbance and restore a sinus rhythm and search for the underlying causes there are many possible variations of the signs this requires judgment before treatment is begun decide on the seriousness of the signs and symptoms and the paramedic must decide if signs and symptoms indicate tachycardia or another condition if the patient is stable and exhibiting related signs related to tachycardia therapy such as vagal maneuvers and medications are recommended if unstable signs and symptoms are determined to result from tachycardia use of electrical therapy with synchronized cardioversion is recommended follow the procedure for emergency care of an adult who has tachycardia with a pulse maintain the airway assist breathing if necessary and apply supplemental oxygen as needed to maintain an spo2 of 94 grader apply the cardiac monitor and monitor the blood pressure pulse ox and get a 12 lead and do not delay emergency care establish an iv infusion of normal saline obtain blood figure stick glucose and treat hypoglycemia if present if the qrs is narrow the patient is stable and there are no contraindications then perform vagal maneuvers if the following rhythm persists then administer adenosine intravenously followed by a dose with a 20 milliliter fluid bolus if the qrs is narrow and the patient is unstable then consider sedation before performing synchronized cardioversion transport the patient for definitive care and follow the recommended treatment guidelines for adult tachycardia with a pulse as shown in figure 17-42 also it's shown on this slide fagal maneuvers alone will terminate up to 25 of svt caused by re-entry attempt before starting medication therapy many types exist in the cardiac sinus massage and the valsalva maneuver okay cardiac massage also known as the carotid sinus pressure assess for brutes before performing this procedure so risk of high thromboembolism in some patients such as those with advanced age coronary disease or high cholesterol the vasava maneuver is more commonly used or the vagal maneuver in which the patient bears down as if attempting to do a bowel movement administer adenosine if the vagal maneuvers are infected and if the patients with the narrow qrs complex remain stable so administer administer at an iv cyclosis to the patient's heart and follow with a 20 ml fluid bolus of normal saline be prepared for a short run of a systole if the first dose of adenosine is unsuccessful then administer a double dose of adenosine and administer it again within one to two minutes if needed repeat the dose again in one to two minutes if a dentist does not convert the rhythm rapidly transport the patient to the medical facility if at any time the condition of svt becomes unstable you should move the unstable arm of the tachycardia algorithm the tachycardia patient in an unstable condition requires electrical therapy with synchronized cardioversion okay so cardioversion is indicated for v-tac and svt associated with severely compromised co sedate the patient first if performing cardioversion on a responsive patient benzodiazepines such as valium and midazolam or versed are commonly administered for sedation follow your local protocol to properly perform cardioversion return refer to your skill dural 17-3 okay so pre-excitation is what we're going to talk about next and this refers to early depolarization of the ventricular tissue by means of an accessory pathway between the atrium ventricular ventricles the accessory pathway is an extra bundle of myocardial tissue that forms a connection between the atria and the ventricles outside the normal conduction system a v reentrant tachycardia is a reentry svt involving an av node and an accessory pathway the most common pre-excitation disorder is wolf parkinson-white syndrome and it's characterized by a short pian r p ri interval non-specific qt wave changes a wide qrs an appearance of a delta wave on the ecg you have lone ganglion levine syndrome and it also causes pre-excitation of the ventricular tissue it's characterized by a short pri interval a normal qrs duration so patients with this white wolf parkinson's white syndrome are suspected susceptible to tachydysrhythmias care of the patient with either of these syndromes include seeking the advice of a physician basing treatment on the gravity of the patient's instability qrx complex with and the ventricular rhythm regularity oh and atrial fibrillation we're going to talk about next it still is originating in the atria a afib is a rhythm in which the atria no longer contracts but instead fibrillates or quivers with no organized contraction the condition occurs when cells in the atria depolarize immediately or independently rather than in response to an sa node impulse a f or a fib results in just fibrillating of the atria a fib is characterized by no visible p wave on the ecg strip no pri to measure irregularity there it's irregularly irregular and afib is common rhythm for older adults afib increases the risk of stroke because blood within the fibrillating atria tends to clot stable but asymptomatic patients may may be prescribed an anticoagulant such as warfarin or coumadin beta blockers calcium channel blockers or digoxin unstable patients may need synchronized cardioversion and pre-hospital treatment for afib is uncommon in stable patients the next rhythm we're going to talk about is a flutter you may flutter is a rhythm in which the atrial impulse fires at a rate too fast for the ventricles to keep up atrial complexes are known as flutter waves or f waves rather than p waves with a distinct sawtooth shape resembling a picket fence one or more of the f waves gets blocked in the avim node resulting in several f waves before each qrs complex the rhythm is usually regular with consistent conduction or irregular with the qrs complex measuring 0.11 seconds or less a flutter can degenerate into afib and patients are often prescribed anticoagulants because these patients are thought to have some type of risk of thromboembolism as patients with a fib a beta blocker calcium channel blocker may be administered if the patient is stable but asymptomatic and synchronized cardioversion may be necessary if the patient is unstable pre-hospital treatment of afib is uncommon in stable patients all right another rhythm originating in the atria is the wandering pacemaker so the wandering pacemaker of the heart moves from the sa node to various locations within the atria or av junction the rate is usually 60 to 100 beats with a slightly irregular rhythm and r on our interval based on the pacemaker site an upright p wave precedes each qrs complex however the p wave shapes vary indicating multiple sites of origin so wondering pacemaker is characterized by a pri of 0.12 to 0.20 seconds and it varies based on the complex origin if seen in children older adults and athletes the treatment is indicated in the pre-hospital setting only if the dysrhythmia is associated with a slow rate and the patient is symptomatic so treatment would be the same for symptomatic sinus bradycardia okay so multifocal atrial tachycardia and they this is otherwise known as matte multiple thetopic sites within the atria depolarize at different but rapid rates and it's characterized by a rate of more than 100 beats per minute in effect multifocal atrial tack is a tachycardic wandering pacemaker within a regular rhythm and pr interval that is varies based on the site of the pacemaker okay so this is the uh it's characterized by a pri of 0.12 to 0.20 seconds however it varies slightly mat is most often seen in patients with a lung disease or pulmonary hypertension coronary disease or some type of hypomagnesium it is also seen in patients undergoing themophylene therapy and treatment is not usually a pre-hospital level and therapies for svt are generally ineffective okay so now we're moving down we're going to move down now into the av junction so after the sa we go into the av the av junction should take over if the sa node fails to initiate that impulse and because the av junction is a secondary pacemaker its intrinsic rate is lower junctional rhythms normally have a rate of about 60 to 40 to 60 beats an impulse generated in the av junction travels down through the conduction system into the ventricles at the same time the impulse travels upward through the atria and internal pathways towards the sa node this leads to three possible circumstances in which the qrs complex appears normal if the impulse begins moving upward through the atria before the other parts enter the ventricles the upside down p wave will slow will show followed immediately by the qrs complex the impulse moving through the atria occurs at the same time it travels through the ventricles the smaller inverted p wave will be hidden within the qrs complex giving the appearance of a missing p wave until a normal qrs complex begins if the impulse starts late through the atria it will result in an inverted p wave after the qrs complex okay so a premature junctional complex is not a dysrhythmia but rather an early complex that appears within a regular rhythm pjcs are also known as etopic complexes meaning they arise from a site other than the sa node the ray depends on the underlying rhythm and is irregular the p wave present the p wave if present will be inverted and may either proceed or follow the qrs complex pjcs are characterized by a pri if present less than 0.12 seconds and the qrs complex measures 0.11 seconds or less pjcs can be caused by many of the same factors that cause a pac pjcs do not normally require treatment and most people with the condition are asymptomatic possible symptoms are perceived skip beats lightheadedness or dizziness okay so junctional escape rhythm is a dysrhythmia that occurs when an sa node does not function and the av node takes over as the pacemaker it is also called the junctional rhythm the rate is going to be between 40 to 60 beats usually regular and with little variation between the r and r intervals so the p wave is inverted or and present before the qrs and junctional rhythm often accompanies sa no disease or increased vagal tone inferior wall mi or other conditions so it can occur after resuscitation from a cardiac arrest treatment depends on the underlying cause but may require a surgery or surgically planted pacemaker and the field atropine should be considered and the tcp may be necessary if the patient's condition is severely compromised accelerated junctional rhythm is present when the rate exceeds the normal rate of 60 beats per minute but remains less than 100 the rhythm is regular with little variation between the r and r intervals and the p wave is present if the p wave is present it's inverted or upside down before or after the qrs complex so it may be associated with digoxin toxicity hypoxia inferior wall and mine rheumatic fever recent cardiac surgery or an electrolyte imbalance and the rate is fast enough to maintain a reasonable co so the patient usually is asymptomatic nevertheless he or she should be closely monitored now junctional attack is accompanied with a rate that exceeds 100 beats the rhythm is regular with little variation between rmr intervals the ecg characteristics are the same as the accelerated junctional but the rate is faster at about 100 beats it's common in adults but it is associated uncommon in adults but is associated with an acute coronary syndrome heart failure or digoxin toxicity because a rate is fast enough to maintain that co it is seldom requires treatment in the pre-hospital setting if the rate exceeds 150 beats co2 or co could suffer so at the rapid ventricular rate distinguishing junctional attack from another narrow qrs tachycardia can be difficult so if the patient's symptomatic then treat in accordance with the tachycardia algorithm all right now we're moving right down the heart and we're going into the rhythms originating in the ventricles so then if the sa node fails to initiate an impulse then the av junction usually takes over however the there is a conversion to pacemaker so the ventricles may start originating their own impulses and become that pacemaker if the av junction does not take over right so you're going to have a y qrs and you're going to be missing p waves so premature ventricular complex once again pvc is not a dysrhythmia but rather an early complex that appears within another rhythm pvcs are atopic complexes because they originate from the site other than the sa node a pvc occurs either or earlier than the next expected sinus complex producing an irregular ventricular rhythm it is characterized by a lack of p wave and no pr interval the qrs complex associated with the pvc measures 0.12 seconds or more a fully compensatory pause usually follows the pvc to determine if one is present so you want to measure the rnr of the underlying rhythm next measure from the r wave to the qrs complex before the pvc to the r wave of the qrs complex and after the pvc a full compensatory pause has occurred if they are on our interval that includes a pvc measure twice that of the underlying rhythm the pvc may be unifocal or multifocal and so unifocal it originates from the same area or focus within the ventricle and look alike multifocal vary in appearance and more than one focus initiating the ventricular impulse and so you can see that on the to the left it's going to be unifocal and to the right you're going to see the multifocal complexes a ventricular couplet is two pvcs with no intervening pause a run of vtac is a term for three or more pvcs in a row also referred to as salvus or burst ventricular by gemini is a pattern that occurs when the complexes become so frequent that they begin to alternate with normal complexes generating a normal pvc than a normal beat then a pvc ventricular trigeminy is a pattern of every third beat being a pvc so it'd be normal normal pvc normal normal pvc and then pvcs can arise in the same ways as a premature atrial injunctional complexes but they most often originate from ischemia in the ventricle tissue they are generally characterized by more serious they're more serious than the premature atrial or junctional complex occasional pvcs are common and usually don't require treatment in otherwise healthy patients but pvcs that occur in patients with heart disease require close monitoring and search for underlying causes okay this next rhythm is the ideoventricular rhythm it occurs when the sa and av nodes fail and the ventricles must paste the heart usually regular with very little variation between the r and r intervals no p wave so no p r i interval the rate is 20 to 40 beats with little variation it's an agonal rhythm pattern created when the ventricular rates lose to the less of 20 beats it may or may not result in a palpable pause pulse treatment improving the co by increasing the rate and if possible treat the underlying cause accelerated idioventricular this rhythm occurs when the inner ventricular rate exceeds the normal upper rate of 40 beats but less than 100 the rhythm is regular with little variation p waves are absent the qrs complex is 0.12 seconds or more accelerated ventricular rhythm may be observed during the first 12 hours of an ami or after reperfusion therapy do not suppress these rhythms with ventricular anti-dysrhythmia agents okay and this is ventricular attack v-tac is a ventricular rhythm that has a rate exceeding 100 beats the rhythm is regular with no variation between the r and r intervals p waves are absent so the pri does not exist qrs complex is 0.12 seconds or more this is considered a wide qrs complex occasionally the qrs complex will vary in height in an alternating pattern and that is polymorphic ventricular attack a wide irregular tachycardia is present in about 25 percent of out of hospital cardiorex cardiac arrest involving ventricular attack the most common is to recite the points it may convert spontaneously to a normal rhythm or it may degenerate into ventricular fib tac is extremely serious and requires treatment if the patient's stable emergency care should focus on treatment with antidysrhythmics if the patient is unstable electric therapy using synchronized cardioversion may be necessary okay and then we have v-fib that rhythm in which the entire heart is just fibrillating okay so it occurs when many different cells become depolarized independently rather than from the sa node impulse there's no p waves there's no pr interval and or no complexes okay so when fibbing waves are greater than three millimeters in amplitude the dysrhythmia is called coarse and when the fib waves are less than three the dysrhythmia is called fine v fib defibrillation so it's effective for v-fib and pulseless v-tac it's a process by which a surge of electrical energy is generated and delivered to the heart defibrillation delivers a current that is powerful enough to depolarize all of the heart's component muscle competent muscle cells when the cells repolarize after the shock they should respond to an impulse from the sa node and begin to organize again so an automatic external defibrillator so an aed interprets the cardiac rhythm to determine if defibrillation is needed in manual defibrillation the paramedic interprets the cardiac rhythm to determine if defibrillation is needed if you witness a cardiac arrest begin chest compressions and attach the defibrillator as soon as available for adults with an unmonitored cardiac arrest or situations where the defibrillator is not available start cpr while the machine is being retrieved and then perform defibrillation as soon as the device is ready aeds and manual defibrillations deliver energy and waveforms so there's monophasic waveforms and that delivers energy from the heart from one defibrillation pad to the other and then there's biphasic and that's when the energy travels from the heart from one defibrillation pad to the other and then reverses the direction flowing back through follow the same safety measures as you would for a manual defibrillation as you would for an aed make sure no one's touching the patient do not defibrillate the patient in water do not defibrillate the patient who is touching metal to avoid burns do not place the defibrillation pads on the medication patch inspect a defibrillator at the beginning of each shift and look for the defibrillation pads cables power supply and monitor to properly perform the manual defibrillation refer to skill drill 17-4 so there can be wearable cardio verter defibrillators and so those were designed for patients at a risk for sudden cardiac death but who are not immediate candidates for therapy with an implantable cardioverter defibrillator example life vest houses a non-adhesive sensing electrode and separate defibrillation electrodes and it constantly reads and records the patient's ecg and up to five biphasic energy shocks can be delivered okay so this is uh systole and a cysticly is the only true arrhythmia the entire heart no longer contracts and this shows no evidence of an organized activity so a systole is a complete absence of a ventricular electrical activity there's no p waves there's no qrs and there's no t waves a flat line on the ecg monitor may or may not indicate a systole so rule out causes of of um other than the systole a sicily is considered non-shockable cardiac arrest rhythm there is no electrical activity to reset and then you have pulseless electrical activity pea refers to an organized so that's the key thing organized cardiac rhythm not accompanied by a detectable pulse pea was formally called electromagnet electromechanical disassociation so mechanical ventricular activity is too weak to produce a palpable pulse as in cases of cardiogenic or hypovolemic shock cardiac tamponade massive pulmonary emboli electrolyte imbalance or disturbance or drug overdose the key to the treatment of pea is to underline or identify the underlying causes and to fix pea is a non-shockable cardiac arrest rhythm okay so this is going to conclude chapter 17 cardiovascular emergencies and we just discussed part three we discussed dysrhythmia interpretation so go ahead and next we're going to do part four and that is going to be working the cardiac arrest and the algorithms for the management of the adult cardiac arrest okay thank you