1) Pulseless electrical activity (PEA) occurs when organized cardiac electrical activity is present but fails to produce adequate mechanical activity and blood flow. 2) Causes of PEA include hypoxia, acidosis, decreased contractility, and increased afterload. 3) Ventricular flutter and fibrillation represent severe irregularities of the heartbeat that can quickly lead to loss of consciousness and death if not treated with defibrillation.

1. Pulseless Electrical Activity
Ventricular flutter, Ventricular fibrillation
DR PRAVEEN GUPTA
29.11.2017
JIPMER
Department of cardiology
Pondicherry
CLT Students class
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2. Introduction
 Characterized by unresponsiveness and lack of palpable pulse in the presence of
organized cardiac electrical activity
 Previously known as electromechanical dissociation (EMD)
 Lack of ventricular electrical activity always implies a lack of ventricular
mechanical activity or asystole, the reverse is not always true
 Electrical activity is a necessary, but not sufficient, condition for mechanical
activity.
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3. Pulseless Electrical Activity
 Meaningful” ventricular mechanical activity, generate a palpable pulse
 True PEA is a condition in which cardiac contractions are absent in the
presence of coordinated electrical activity
 Absence of peripheral pulses should not be equated with PEA, as it may be
due to severe PVD
 PEA encompasses a number of organized cardiac rhythms, including
supraventricular rhythms (sinus versus nonsinus) and ventricular rhythms
(accelerated idioventricular or escape)
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4. Pathophysiology
 Occurs when a major cardiovascular, respiratory, or metabolic derangement
results in the inability of cardiac muscle to generate sufficient force in
response to electrical depolarization.
 The initial insult weakens cardiac contraction, and this situation is
exacerbated by worsening acidosis, hypoxia, and increasing vagal tone.
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5. Pathophysiology of PEA
 Compromise of the inotropic state leads to inadequate mechanical activity
 Creates a vicious cycle, degeneration of the rhythm and death
 Hypoxia secondary to respiratory failure is most common cause of PEA,
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6. Etiology of PEA
 Decreased preload
 Increased afterload
 Decreased contractility
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8. Prognosis
 Females are more likely to develop PEA than males
 Prognosis is poor unless reversible cause is identified and corrected
 ECG wider QRS (>0.2 s), fare worse
 Out-of-hospital PEA likely to recover then in hospital PEA
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10. Ventricular Flutter and Fibrillation
 Represent severe derangements of the heartbeat that can terminate fatally or
produce significant brain damage within 3 to 5 minutes
 Ventricular flutter manifested as a sine wave in appearance—regular large
oscillations occurring at a rate of 150 to 300 beats/minute
 VF is recognized by presence of irregular undulations of varying contour &
amplitude . Distinct QRS , ST , and T waves absent.
 Fine-amplitude fibrillatory waves (0.2 mV) are present with prolonged VF.
 Fine waves identify worse survival rates & confused with asystole.
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11. Ventricular flutter
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12. Ventricular fibrillation
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13. Clinical Features
 Ventricular flutter or VF results in faintness, loss of consciousness,
seizures, apnea, and eventually death.
 Blood pressure is unobtainable, and heart sounds are usually absent.
 Atria can continue to beat at an independent rhythm for a time or in
response to impulses from the fibrillating ventricles.
 Eventually, electrical activity of the heart ceases
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14. Mechanisms
 VF occurs most commonly in association with coronary artery disease
 VF, occur mostly in the morning
 Occur during antiarrhythmic drug administration, hypoxia, ischemia, or AF
that results in very rapid ventricular rates in patients with preexcitation
syndrome; after electrical shock administered during cardioversion or
accidentally by improperly grounded equipment; and during competitive
ventricular pacing to terminate VT.
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15. Management
 Basic life support and advanced cardiac life support
 Immediate nonsynchronized DC shock (200 to 400 J) for VF, ventricular
flutter, and pulseless VT.
 CPR is performed only until the defibrillation equipment ready
 If the circulation is markedly inadequate despite return to sinus rhythm,
closed-chest massage should be instituted.
 After conversion to a normal rhythm, monitor rhythm continuously and to
institute measures to prevent recurrence.
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17. References
 Emedicine
 Braunwald’s Heart Disease A Textbook of Cardiovascular Medicine, 10TH
Edition
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