Pulseless electrical activity differential diagnosis: Difference between revisions

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| [[File:Siren.gif|30px|link= Pulseless electrical activity resident survival guide]]|| <br> || <br>
| [[Pulseless electrical activity resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
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{{Pulseless electrical activity}}
{{Pulseless electrical activity}}
{{CMG}}
{{CMG}},{{AE}} {{M.N}}
 
==Overview==
==Overview==
==Differentiating PEA From Other Disorders Causing Cardiac Arrest==
PEA(Pulseless electrical activity) should be differentiated from [[asystole]] and [[ventricular fibrillation]], [[Ventricular flutter]], [[Torsade de Pointes]], [[Asystole]] etc.
 
==Differentiating Pulseless Electrical Activity from Other Diseases==
*[[Asystole]]: In [[asystole]], there is cessation of any cardiac activity and lack of cardiac output on this basis.  In PEA, electrical activity is present.
*[[Asystole]]: In [[asystole]], there is cessation of any cardiac activity and lack of cardiac output on this basis.  In PEA, electrical activity is present.
*[[Ventricular fibrillation]]: There is no organized electrical activity present.  There are only fine fibrillatory waves present in ventricular fibrillation. In PEA, there is organized electrical activity.
*[[Ventricular fibrillation]]: There is no organized electrical activity present.  There are only fine fibrillatory waves present in ventricular fibrillation. In PEA, there is organized electrical activity.
*[[Peripheral arterial disease]]: The inability to feel a peripheral pulse may be due to severe [[peripheral arterial disease]].
*[[Peripheral arterial disease]]: The inability to feel a peripheral pulse may be due to severe [[peripheral arterial disease]].
The table below provides information on the differential diagnosis of pulseless electrical activity in terms of ECG appearance:
{| border="3"
|+
! style="background: #4479BA; width: 150px;" | {{fontcolor|#FFF| Disease Name}}
! style="background: #4479BA; width: 150px;" | {{fontcolor|#FFF| Causes}}
! style="background: #4479BA; width: 150px;" | {{fontcolor|#FFF| ECG Characteristics}}
! style="background: #4479BA; width: 150px;" | {{fontcolor|#FFF| ECG view}}
|-
! style="padding: 5px 5px; background: #DCDCDC; " align="left"| '''[[Ventricular tachycardia]]''' <ref name="AjijolaTung2014">{{cite journal|last1=Ajijola|first1=Olujimi A.|last2=Tung|first2=Roderick|last3=Shivkumar|first3=Kalyanam|title=Ventricular tachycardia in ischemic heart disease substrates|journal=Indian Heart Journal|volume=66|year=2014|pages=S24–S34|issn=00194832|doi=10.1016/j.ihj.2013.12.039}}</ref><ref name="Meja LopezMalhotra2019">{{cite journal|last1=Meja Lopez|first1=Eliany|last2=Malhotra|first2=Rohit|title=Ventricular Tachycardia in Structural Heart Disease|journal=Journal of Innovations in Cardiac Rhythm Management|volume=10|issue=8|year=2019|pages=3762–3773|issn=21563977|doi=10.19102/icrm.2019.100801}}</ref><ref name="CoughtrieBehr2017">{{cite journal|last1=Coughtrie|first1=Abigail L|last2=Behr|first2=Elijah R|last3=Layton|first3=Deborah|last4=Marshall|first4=Vanessa|last5=Camm|first5=A John|last6=Shakir|first6=Saad A W|title=Drugs and life-threatening ventricular arrhythmia risk: results from the DARE study cohort|journal=BMJ Open|volume=7|issue=10|year=2017|pages=e016627|issn=2044-6055|doi=10.1136/bmjopen-2017-016627}}</ref><ref name="El-Sherif2001">{{cite journal|last1=El-Sherif|first1=Nabil|title=Mechanism of Ventricular Arrhythmias in the Long QT Syndrome: On Hermeneutics|journal=Journal of Cardiovascular Electrophysiology|volume=12|issue=8|year=2001|pages=973–976|issn=1045-3873|doi=10.1046/j.1540-8167.2001.00973.x}}</ref><ref name="de RivaWatanabe2015">{{cite journal|last1=de Riva|first1=Marta|last2=Watanabe|first2=Masaya|last3=Zeppenfeld|first3=Katja|title=Twelve-Lead ECG of Ventricular Tachycardia in Structural Heart Disease|journal=Circulation: Arrhythmia and Electrophysiology|volume=8|issue=4|year=2015|pages=951–962|issn=1941-3149|doi=10.1161/CIRCEP.115.002847}}</ref>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
*[[Ischemic heart disease]]
*Illicit drug use such as [[cocaine]] and [[methamphetamine]]
*[[Structural heart diseases]]
*[[Electrolyte disturbances]]
*[[Congestive heart failure]]
*[[Myocarditis]]
*[[Obstructive sleep apnea]]
*[[Pulmonary artery catheter]]
*[[Long QT syndrome]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
*[[Ventricular tachycardia (patient information)|Ventricular tachycardia]] originates from a [[ventricular]] focus.
* Lasts more than 30 seconds.
* [[Broad QRS complex]]es: rate of >90 BPM.
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
[[File:Capture V tach.PNG|center|300px]]<ref> ECG found in of https://en.ecgpedia.org/index.php?title=Main_Page </ref>
|-
! style="padding: 5px 5px; background: #DCDCDC; " align="left"| '''[[Ventricular fibrillation]]''' <ref name="pmid19252119">{{cite journal |vauthors=Koplan BA, Stevenson WG |title=Ventricular tachycardia and sudden cardiac death |journal=Mayo Clin. Proc. |volume=84 |issue=3 |pages=289–97 |date=March 2009 |pmid=19252119 |pmc=2664600 |doi=10.1016/S0025-6196(11)61149-X |url=}}</ref><ref name="pmid28222965">{{cite journal |vauthors=Maury P, Sacher F, Rollin A, Mondoly P, Duparc A, Zeppenfeld K, Hascoet S |title=Ventricular arrhythmias and sudden death in tetralogy of Fallot |journal=Arch Cardiovasc Dis |volume=110 |issue=5 |pages=354–362 |date=May 2017 |pmid=28222965 |doi=10.1016/j.acvd.2016.12.006 |url=}}</ref><ref name="pmid1638716">{{cite journal |vauthors=Saumarez RC, Camm AJ, Panagos A, Gill JS, Stewart JT, de Belder MA, Simpson IA, McKenna WJ |title=Ventricular fibrillation in hypertrophic cardiomyopathy is associated with increased fractionation of paced right ventricular electrograms |journal=Circulation |volume=86 |issue=2 |pages=467–74 |date=August 1992 |pmid=1638716 |doi=10.1161/01.cir.86.2.467 |url=}}</ref><ref name="BektasSoyuncu2012">{{cite journal|last1=Bektas|first1=Firat|last2=Soyuncu|first2=Secgin|title=Hypokalemia-induced Ventricular Fibrillation|journal=The Journal of Emergency Medicine|volume=42|issue=2|year=2012|pages=184–185|issn=07364679|doi=10.1016/j.jemermed.2010.05.079}}</ref>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
*[[Coronary ischemia|Acute coronary ischemia]]
*[[cardiomyopathy|Cardiomyopathies]]
*[[Congenital heart disease]]
*[[Myocardial infarction]]
*[[Heart surgery]]
*[[Electrolyte abnormalities]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Poorly identifiable [[QRS complexes]] and absent [[P waves]]
* The [[heart rate]] is >300 BPM
*[[Rhythm]] is irregular
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
[[File:Capture VF.PNG|center|300px]]<ref> ECG found in https://en.ecgpedia.org/index.php?title=Main_Page </ref>
|-
! style="padding: 5px 5px; background: #DCDCDC; " align="left"| '''[[Ventricular flutter]]''' <ref name="ThiesBoos2000">{{cite journal|last1=Thies|first1=Karl-Christian|last2=Boos|first2=Karin|last3=Müller-Deile|first3=Kai|last4=Ohrdorf|first4=Wolfgang|last5=Beushausen|first5=Thomas|last6=Townsend|first6=Peter|title=Ventricular flutter in a neonate—severe electrolyte imbalance caused by urinary tract infection in the presence of urinary tract malformation|journal=The Journal of Emergency Medicine|volume=18|issue=1|year=2000|pages=47–50|issn=07364679|doi=10.1016/S0736-4679(99)00161-4}}</ref><ref name="KosterWellens1976">{{cite journal|last1=Koster|first1=Rudolph W.|last2=Wellens|first2=Hein J.J.|title=Quinidine-induced ventricular flutter and fibrillation without digitalis therapy|journal=The American Journal of Cardiology|volume=38|issue=4|year=1976|pages=519–523|issn=00029149|doi=10.1016/0002-9149(76)90471-9}}</ref><ref name="pmid250503">{{cite journal |vauthors=Dhurandhar RW, Nademanee K, Goldman AM |title=Ventricular tachycardia-flutter associated with disopyramide therapy: a report of three cases |journal=Heart Lung |volume=7 |issue=5 |pages=783–7 |date=1978 |pmid=250503 |doi= |url=}}</ref>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
*[[Electrolyte disturbances]]
*[[Medications]] such as:
**[[Disopyramide]]
**[[Quinidine]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
*The [[ECG]] shows:
**A typical [[sinusoidal]] pattern
**Frequency of 300 bpm
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
[[File:Capture Ven Flu.PNG|center|300px]]<ref> ECG found in https://en.ecgpedia.org/index.php?title=Main_Page </ref>
|-
! style="padding: 5px 5px; background: #DCDCDC;" align="left" | '''[[Asystole]]''' <ref name="ACLS_2003_H_T">''ACLS: Principles and Practice''. p. 71-87. Dallas: American Heart Association, 2003. ISBN 0-87493-341-2.</ref><ref name="ACLS_2003_EP_HT">''ACLS for Experienced Providers''. p. 3-5. Dallas: American Heart Association, 2003. ISBN 0-87493-424-9.</ref>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
*[[Hypovolemia]]
*[[Hypoxia (medical)|Hypoxia]]
*[[Acidosis]]
*[[Hypothermia|Hypothermia]]
*[[Hyperkalemia|Hyperkalemia]] or [[Hypokalemia|Hypokalemia]]
*[[Hypoglycemia|Hypoglycemia]]
*[[Cardiac tamponade|Cardiac Tamponade]]
*[[Tension pneumothorax|Tension pneumothorax]]
*[[Thrombosis|Thrombosis]]
*[[Myocardial infarction]]
*[[Thrombosis|Thrombosis]]
*[[Pulmonary embolism]]
*[[Cardiogenic shock]]
*Degeneration of the [[sinoatrial]] or [[atrioventricular]] nodes
*[[Ischemic stroke]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* There is no electrical activity in the asystole
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
[[Image:Lead II rhythm generated asystole.JPG|center|300px]]<ref> ECG found in https://en.ecgpedia.org/index.php?title=Main_Page </ref>
|-
! style="padding: 5px 5px; background: #DCDCDC;" align="left" | '''[[Pulseless electrical activity]]''' <ref name="ECC_2005_7.2">"2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care - Part 7.2: Management of Cardiac Arrest." ''Circulation'' 2005; '''112''': IV-58 - IV-66.</ref><ref>Foster B, Twelve Lead Electrocardiography, 2nd edition, 2007</ref><ref name="pmid24297818">{{cite journal |vauthors=Myerburg RJ, Halperin H, Egan DA, Boineau R, Chugh SS, Gillis AM, Goldhaber JI, Lathrop DA, Liu P, Niemann JT, Ornato JP, Sopko G, Van Eyk JE, Walcott GP, Weisfeldt ML, Wright JD, Zipes DP |title=Pulseless electric activity: definition, causes, mechanisms, management, and research priorities for the next decade: report from a National Heart, Lung, and Blood Institute workshop |journal=Circulation |volume=128 |issue=23 |pages=2532–41 |date=December 2013 |pmid=24297818 |doi=10.1161/CIRCULATIONAHA.113.004490 |url=}}</ref><ref name="pmid23949188">{{cite journal |vauthors=Littmann L, Bustin DJ, Haley MW |title=A simplified and structured teaching tool for the evaluation and management of pulseless electrical activity |journal=Med Princ Pract |volume=23 |issue=1 |pages=1–6 |date=2014 |pmid=23949188 |pmc=5586830 |doi=10.1159/000354195 |url=}}</ref>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
*[[Hypovolemia]]
*[[Hypoxia]]
*Hydrogen ions ([[Acidosis]])
*[[Hypothermia]]
*[[Electrolyte disturbances]]
*[[Hypoglycemia]]
*[[Tablets]] or [[Toxins]] (Drug overdose) such as [[beta blockers]], [[tricyclic antidepressants]], or [[calcium channel blockers]]
*[[Tamponade]]
*[[Tension pneumothorax]]
*[[Thrombosis]] ([[Myocardial infarction]])
*[[Thrombosis]] ([[Pulmonary embolism]])
*[[Trauma]] ([[Hypovolemia]] from [[blood loss]])
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
*Several pattern are possible including:
**[[Normal sinus rhythm]]
**[[Sinus tachycardia]], with discernible [[P waves]] and [[QRS complexes]]
**[[Bradycardia]], with or without [[P waves]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
[[File:Capture PEA.PNG|center|300px]]<ref> ECG found in wikimedia Commons </ref>
|-
! style="padding: 5px 5px; background: #DCDCDC;" align="left" |'''[[Torsade de Pointes]]''' <ref name="pmid28674475">{{cite journal |vauthors=Li M, Ramos LG |title=Drug-Induced QT Prolongation And Torsades de Pointes |journal=P T |volume=42 |issue=7 |pages=473–477 |date=July 2017 |pmid=28674475 |pmc=5481298 |doi= |url=}}</ref><ref name="SharainMay2015">{{cite journal|last1=Sharain|first1=Korosh|last2=May|first2=Adam M.|last3=Gersh|first3=Bernard J.|title=Chronic Alcoholism and the Danger of Profound Hypomagnesemia|journal=The American Journal of Medicine|volume=128|issue=12|year=2015|pages=e17–e18|issn=00029343|doi=10.1016/j.amjmed.2015.06.051}}</ref><ref name="pmid11330748">{{cite journal |vauthors=Khan IA |title=Twelve-lead electrocardiogram of torsades de pointes |journal=Tex Heart Inst J |volume=28 |issue=1 |pages=69 |date=2001 |pmid=11330748 |pmc=101137 |doi= |url=}}</ref>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* *[[Electrolyte disturbances]]
*[[Medications]] such as:
**[[Amiodarone]]
**[[Azithromycin]]
**[[Clozapine]]
**[[Famotidine]]
**[[Flecainide]]
**[[Foscarnet]]
**[[Levofloxacin]]
**[[Lithium]]
**[[Mirtazapine]]
**[[Quetiapine]]
**[[Risperidone]]
**[[Tacrolimus]]
**[[Tamoxifen]]
**[[Ziprasidone]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
# Paroxysms of [[VT]] with irregular RR intervals.
# A [[ventricular]] rate between 200 and 250 beats per minute.
# Two or more cycles of [[QRS complex]]es with alternating polarity.
# Changing amplitude of the [[QRS complexes]] in each cycle in a [[sinusoidal]] fashion.
# Prolongation of the [[QT interval]].
# Is often initiated by a [[PVC]] with a long coupling interval, R on T phenomenon.
# There are usually 5 to 20 complexes in each cycle.
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
[[File:Capture Tors De P.PNG|center|300px]]<ref> ECG found in https://en.ecgpedia.org/index.php?title=Main_Page </ref>
|}


==References==
==References==
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[[Category:Disease]]
[[Category:Electrophysiology]]
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Latest revision as of 22:28, 7 July 2020
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1],Associate Editor(s)-in-Chief: Maneesha Nandimandalam, M.B.B.S.[2]

Overview

PEA(Pulseless electrical activity) should be differentiated from asystole and ventricular fibrillation, Ventricular flutter, Torsade de Pointes, Asystole etc.

Differentiating Pulseless Electrical Activity from Other Diseases

The table below provides information on the differential diagnosis of pulseless electrical activity in terms of ECG appearance:

Disease Name Causes ECG Characteristics ECG view
Ventricular tachycardia [1][2][3][4][5]
[6]
Ventricular fibrillation [7][8][9][10]
[11]
Ventricular flutter [12][13][14]
[15]
Asystole [16][17]
  • There is no electrical activity in the asystole
[18]
Pulseless electrical activity [19][20][21][22]
[23]
Torsade de Pointes [24][25][26]
  1. Paroxysms of VT with irregular RR intervals.
  2. A ventricular rate between 200 and 250 beats per minute.
  3. Two or more cycles of QRS complexes with alternating polarity.
  4. Changing amplitude of the QRS complexes in each cycle in a sinusoidal fashion.
  5. Prolongation of the QT interval.
  6. Is often initiated by a PVC with a long coupling interval, R on T phenomenon.
  7. There are usually 5 to 20 complexes in each cycle.
[27]

References

  1. ↑ Ajijola, Olujimi A.; Tung, Roderick; Shivkumar, Kalyanam (2014). "Ventricular tachycardia in ischemic heart disease substrates". Indian Heart Journal. 66: S24–S34. doi:10.1016/j.ihj.2013.12.039. ISSN 0019-4832.
  2. ↑ Meja Lopez, Eliany; Malhotra, Rohit (2019). "Ventricular Tachycardia in Structural Heart Disease". Journal of Innovations in Cardiac Rhythm Management. 10 (8): 3762–3773. doi:10.19102/icrm.2019.100801. ISSN 2156-3977.
  3. ↑ Coughtrie, Abigail L; Behr, Elijah R; Layton, Deborah; Marshall, Vanessa; Camm, A John; Shakir, Saad A W (2017). "Drugs and life-threatening ventricular arrhythmia risk: results from the DARE study cohort". BMJ Open. 7 (10): e016627. doi:10.1136/bmjopen-2017-016627. ISSN 2044-6055.
  4. ↑ El-Sherif, Nabil (2001). "Mechanism of Ventricular Arrhythmias in the Long QT Syndrome: On Hermeneutics". Journal of Cardiovascular Electrophysiology. 12 (8): 973–976. doi:10.1046/j.1540-8167.2001.00973.x. ISSN 1045-3873.
  5. ↑ de Riva, Marta; Watanabe, Masaya; Zeppenfeld, Katja (2015). "Twelve-Lead ECG of Ventricular Tachycardia in Structural Heart Disease". Circulation: Arrhythmia and Electrophysiology. 8 (4): 951–962. doi:10.1161/CIRCEP.115.002847. ISSN 1941-3149.
  6. ↑ ECG found in of https://en.ecgpedia.org/index.php?title=Main_Page
  7. ↑ Koplan BA, Stevenson WG (March 2009). "Ventricular tachycardia and sudden cardiac death". Mayo Clin. Proc. 84 (3): 289–97. doi:10.1016/S0025-6196(11)61149-X. PMC 2664600. PMID 19252119.
  8. ↑ Maury P, Sacher F, Rollin A, Mondoly P, Duparc A, Zeppenfeld K, Hascoet S (May 2017). "Ventricular arrhythmias and sudden death in tetralogy of Fallot". Arch Cardiovasc Dis. 110 (5): 354–362. doi:10.1016/j.acvd.2016.12.006. PMID 28222965.
  9. ↑ Saumarez RC, Camm AJ, Panagos A, Gill JS, Stewart JT, de Belder MA, Simpson IA, McKenna WJ (August 1992). "Ventricular fibrillation in hypertrophic cardiomyopathy is associated with increased fractionation of paced right ventricular electrograms". Circulation. 86 (2): 467–74. doi:10.1161/01.cir.86.2.467. PMID 1638716.
  10. ↑ Bektas, Firat; Soyuncu, Secgin (2012). "Hypokalemia-induced Ventricular Fibrillation". The Journal of Emergency Medicine. 42 (2): 184–185. doi:10.1016/j.jemermed.2010.05.079. ISSN 0736-4679.
  11. ↑ ECG found in https://en.ecgpedia.org/index.php?title=Main_Page
  12. ↑ Thies, Karl-Christian; Boos, Karin; Müller-Deile, Kai; Ohrdorf, Wolfgang; Beushausen, Thomas; Townsend, Peter (2000). "Ventricular flutter in a neonate—severe electrolyte imbalance caused by urinary tract infection in the presence of urinary tract malformation". The Journal of Emergency Medicine. 18 (1): 47–50. doi:10.1016/S0736-4679(99)00161-4. ISSN 0736-4679.
  13. ↑ Koster, Rudolph W.; Wellens, Hein J.J. (1976). "Quinidine-induced ventricular flutter and fibrillation without digitalis therapy". The American Journal of Cardiology. 38 (4): 519–523. doi:10.1016/0002-9149(76)90471-9. ISSN 0002-9149.
  14. ↑ Dhurandhar RW, Nademanee K, Goldman AM (1978). "Ventricular tachycardia-flutter associated with disopyramide therapy: a report of three cases". Heart Lung. 7 (5): 783–7. PMID 250503.
  15. ↑ ECG found in https://en.ecgpedia.org/index.php?title=Main_Page
  16. ↑ ACLS: Principles and Practice. p. 71-87. Dallas: American Heart Association, 2003. ISBN 0-87493-341-2.
  17. ↑ ACLS for Experienced Providers. p. 3-5. Dallas: American Heart Association, 2003. ISBN 0-87493-424-9.
  18. ↑ ECG found in https://en.ecgpedia.org/index.php?title=Main_Page
  19. ↑ "2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care - Part 7.2: Management of Cardiac Arrest." Circulation 2005; 112: IV-58 - IV-66.
  20. ↑ Foster B, Twelve Lead Electrocardiography, 2nd edition, 2007
  21. ↑ Myerburg RJ, Halperin H, Egan DA, Boineau R, Chugh SS, Gillis AM, Goldhaber JI, Lathrop DA, Liu P, Niemann JT, Ornato JP, Sopko G, Van Eyk JE, Walcott GP, Weisfeldt ML, Wright JD, Zipes DP (December 2013). "Pulseless electric activity: definition, causes, mechanisms, management, and research priorities for the next decade: report from a National Heart, Lung, and Blood Institute workshop". Circulation. 128 (23): 2532–41. doi:10.1161/CIRCULATIONAHA.113.004490. PMID 24297818.
  22. ↑ Littmann L, Bustin DJ, Haley MW (2014). "A simplified and structured teaching tool for the evaluation and management of pulseless electrical activity". Med Princ Pract. 23 (1): 1–6. doi:10.1159/000354195. PMC 5586830. PMID 23949188.
  23. ↑ ECG found in wikimedia Commons
  24. ↑ Li M, Ramos LG (July 2017). "Drug-Induced QT Prolongation And Torsades de Pointes". P T. 42 (7): 473–477. PMC 5481298. PMID 28674475.
  25. ↑ Sharain, Korosh; May, Adam M.; Gersh, Bernard J. (2015). "Chronic Alcoholism and the Danger of Profound Hypomagnesemia". The American Journal of Medicine. 128 (12): e17–e18. doi:10.1016/j.amjmed.2015.06.051. ISSN 0002-9343.
  26. ↑ Khan IA (2001). "Twelve-lead electrocardiogram of torsades de pointes". Tex Heart Inst J. 28 (1): 69. PMC 101137. PMID 11330748.
  27. ↑ ECG found in https://en.ecgpedia.org/index.php?title=Main_Page

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