Pvc's/Pacemaker HELP!

[manda0125]

Hello everyone, Im fairly new to the cardiac unit and I'm really confused about a patient I had the other day and would appreciate some knowledge anyone has to offer My patient HR on the tele monitor was 77-80 Bigeminy (asymptomatic) when the cna did his VS with the pulse ox his HR was 40's so I listened for an apical and also palpated a radial pulse and got 46 I understand that the monitor may be reading thatbut because he wasnt actually perfusing I got the 46 but he did have a pacemaker so should that have been kicking in? and when I called the cardiologist to report the rhythm and ACTUAL rate he didnt seem concerned! ( the patient came in with CP but had a negative stress test that AM but had a hx of cabgx4, MI)

[CCL RN, RN]

Well, his RATE was 77-80. His PULSE was 46. Rate and pulse are two different measurements.

PVCs don't typically perfuse, therefore not producing a pulse.

This all seems right. I guess I don't understand your question? Everything seems in order...

And pacers don't start to work based on a single beat of our hearts. Instead, it usually takes a few seconds of bradycardia before a pacer kicks in, usually the rate is set at 50 or 60.

Plus, your pt was asymptomatic. Fantastic! :redpinkhe

Was the bigem new onset or present when you came on shift?

[LoveANurse09]

quick trick: when looking at a 6 sec strip. Count the number of normal beats, not PVC's. This is then your estimated rate. Example: if there are 5 normal beats and 5 PVC's. The rate is about 50 bpm.

[manda0125]

let me re -state the question, since his ACTUAL perfusion rate was indeed in the 40's wouldnt one hold cardiac meds that would further lower his rate? the confusion comes in because the nurses were counting the pvc's with the rate so since he was in begeminy and the tele said 82 his ACTUAL rate was half that

[nursej22, MSN, RN]

Not knowing what kind of pacemaker or the settings here is a guess:

Pacemakers trigger or inhibit an impulse based on what they sense. If it senses a ventricular depolarization, they will wait a preprogrammed amount of time before firing. The pacer itself cannot sense whether the beat perfused or not. Thus even though the low rate may be set 50 or 60, it won't pace that fast if it is sensing a rate higher than that.

You didn't say what meds you were concerned about nor the BP. The doc probably wanted the meds given to suppress the PVCs, as long as the patient was asymptomatic.

[GoodNP]

let me re -state the question, since his ACTUAL perfusion rate was indeed in the 40's wouldnt one hold cardiac meds that would further lower his rate? the confusion comes in because the nurses were counting the pvc's with the rate so since he was in begeminy and the tele said 82 his ACTUAL rate was half that

Since there is a PM, you don't have to worry about the rate going too low. In fact, BBs and some CCBs like Diltiazem will help reduce ectopy (yes, CCBs do have some effect on VE), so you will end seeing more regular or paced beats instead of so many PVCs. If on the other hand, your patient showed signs of poor perfusion, such as hypotension, then you may consider holding BP meds.