Rythym question - page 2

Ok folks I'm stumped. I monitored a pt who I'd have liked to have in my unit, not on the floor on tele, and who had a rythym I've never seen the likes of before. I'll describe it, and y'all tell me if you've seen this. ... Read More

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    Well I got a look at the cardiac consult which said sick sinus syndrome for the particular bit that I was concerned with. My boss disagreed and said it was second degree block type two, with escape beats. You know, that 2nd degree type 2 is the one thing I try not to see. There shouldn't be any bias when reading strips I guess, but that's usually the last thing I'll think- I'll say third degree first. Hm.

    History: female, forties, no smoking or drinking or drug use, myositis is the prominent history, also known as fibromyalgia syndrome. Previous to this arrythmia, she had psvt, pneumonia, flu, arthritis-like foot problems, and other stuff I don't readily remember on the history. Presented with elevated ck, elevated ck-mb and elevated troponin, but only 1mm ST elevations in the telemetry and ekg. The ekg only caught the sinus with bundle, not the second degree with ectopy so it was very little help to me.
    Complained of chest pain relieved by nitro and morphine, also right upper quadrant pain with what felt like a firm liver to me. No firm diagnosis of the fibromyalgia or myositis so other than NSAIDS, not much specific to treat autoimmune type disorders. Oh, yes and I think the ectopic beats were perfusing, but irregularly so as the radial pulse I got was very irregular both in strength and rate.

    She went home, did not have any other complications and I'll be interested to see how she does if she comes back to see us. I did find reference to some papers on myositis and heart block that did not seem to have a good outlook on the situation with that type of development, although it is a rare occurrance. My lesson learned is to keep a sharper eye out for my second degree blocks.

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  2. 0
    I'd love to see this strip... post it if/when you get it...

    If you have a consistent PR you can map without considering the PVCs then you can't have a third degree... you'd have a second degree... if the PRI is pretty consistent then a pause... it seems like you are on the verge of losing that AV conduction down through the bundle... can you describe more of what you are calling the PVC?... could it possibly be an escape beat (like you mentioned already) kicking in after a nonconducted p wave after a 2:1 block? Are there any inverted p waves from regtrograde conduction? Is the QRS "ectopic" beat isoelectrically opposite the p conducted QRS complexes? Are her lytes normal?

    Next question... what happens between when the paired complexes end and the new sinus sequence begins?

    Maybe it's just "ASB"....

    ..."attention seeking behavior"....

    just kidding...

    very intersting rhythm... the cardiologist didn't commit to calling it anything?

    I'll check back on this thread, thanks for posting this!
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    Was the patient stable? What was the BP? Any vasopressors? A third degree block will not have the same PRI on the one consistent normal sinus beat that you mentioned that occurred just before the funny little beats (FLB's). You may be looking at things too closely or too hard. Sometimes an explanation is unrealistic, such as a heart rate of 20 to 30 on an alert, oriented old lady with a systolic bp of 180. I have seen that, which defies logic.
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    The cardiologist called it sick sinus syndrome. BP 130's/80's. No vasopressors, and the pvc's were not all the same. All pointed the same direction, but some were big, "normal" looking things and some were rather squashed looking. The patient was stable, talkative, and had decent symptom relief by the time I saw her.

    I don't get ready access to materials to copy once they've left my monitoring shift, so likelihood of posting is less than that of my house sprouting wings, unfortunately. You know how it is with education- bosses like it their way. I do still intend to have her chart pulled back out so I can get another good look, and I requested an actual inservice. :-) If I see the cardiologist when he's not in a huge hurry I will ask him as well.

    Having turned it over a bit more in my brain, I see now that yes, I should have seen second degree block. Which is fine, but what messes with my head now is why the pvc's (what ever in this fine world you wanna call them) wind up in the spot they do. I'd even be okay with second degree with bigeminy if the darn things would just not be glued to the tail end of a sinus beat. I really think her block is progressive and it's gonna be third degree at some point in the not so far off future.

    Well anyhow I've probably beaten this poor horse, er rythym, to death. Gotta sleep now!
  5. 0
    Sick sinus?!!! Yes to marked bradycardia, sinus pauses or periods of sinus arrest... but then sick sinus alternates that paroxysms of rapid atrial arrhythmias, especially atrial flutter or a-fib.... aka brady-tachy syndrome. During the periods of brady sometimes junctional escape rhythms commonly occur and AV block is also often associated with sick sinus (which is why I was asking about inverted p's related to retrograde conduction)... but hmmm... I didn't see anything about the rapid rhythms in the original post.... causes of sick sinus include inflammatory cardiac disease, cardiomyopathy, sclerodegenerative processes involving both the sinus and AV nodes, drugs like beta blockers, calcium channel blockers, dig, amio, propafenone and adenosine. Bummer about getting the strip posted... and I hear you about the education and management liking it that way...on my old unit I recently heard from an insider at a management meeting that they weren't going to orient all the nurses to recovering the post op CABGs because then they'd all have an advanced skill set and some of them would leave... geezzz.... just unbelievable isn't it?
  6. 0
    That's just silly... not like an advanced skill set would benefit patients, huh?
  7. 0
    Yupp, just nonsense... I couldn't believe it when I heard it... what they don't realize is that the good nurses elevate themselves wherever they are and if a unit or a hospital is an impediment to such they go elsewhere... leave anyway... and the problem isn't solved on administration's end in the outcome...good nurses will seek out the experiences they want and need...This is why my old unit is stocked with agency and travelers... no one in the hospital wants to work there...

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