Rythym question

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    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. Occasionally she's sinus, PRI of .15 or .16, brady in 50s with a right bundle block, no big deal. Then there's a pause, sometimes 1 sec, sometimes long enough to make the monitor go nuts, then we get paired beats. The pairs are such that the first one in the pair has a PRI of about .16 and it looks just like the sinus beats did. The second one in the pair is a pvc. It should just be bigeminy but the pvc's vary in size, still unifocal, and some of them look like little escape beats. The distance between the pairs is fairly consistent, but longer than I would like for a compensatory pause to be. I'm used to bigeminy looking like almost equal distance between most of the beats, it doesn't bunch up into pairs.

    I ran a deskfull of strips on this lady, got my eyeballs to vibrating eventually and I am convinced this is 3rd degree block with the p waves hidden in the T after each pvc. It just takes being either really picky or truly hallucinating to find 'em. I can't decide which I was doing. I did try looking this stuff up, I can't find examples of anything that looks like this.
    And the troponin was up, there was a little ST elevation, maybe 1 mm.
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    Have you had an EKG done on the patient?
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    A few questions, and maybe Im reading what you are trying to say wrong, but how were you getting a PRI with the P buried in the T? I have actually seen something similar to this which I thought was third degree heart block with BB and ended up being some type of rarely seen Slow afib with a BBB. Did you happen to check a dig level on this patient? Im still a bit confused. Were you able to see ANY P waves? The unifocal PVC's, were of varying size, but still unifocal correct? I would love to see a stip of this if you could scan it. If you mark out the stip name you should be able to post it. One last question, what was the patients Blood Pressure with this rhythm?
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    Quote from joeyzstj
    A few questions, and maybe Im reading what you are trying to say wrong, but how were you getting a PRI with the P buried in the T? I have actually seen something similar to this which I thought was third degree heart block with BB and ended up being some type of rarely seen Slow afib with a BBB. Did you happen to check a dig level on this patient? Im still a bit confused. Were you able to see ANY P waves? The unifocal PVC's, were of varying size, but still unifocal correct? I would love to see a stip of this if you could scan it. If you mark out the stip name you should be able to post it. One last question, what was the patients Blood Pressure with this rhythm?
    Okay, let me clarify. And I don't go back to work till tuesday, so I won't have any kind of update until then. We'd have, a p wave, PRI of 0.15 to 0.16, then immediately after, a pvc, with a notch in the t wave of that pvc, then something about 1 second, sometimes longer, of isoelectric line with fine artifact that you could just BARELY make out a p wave in the middle of, (no complex following and that is if you think that's a p wave in the artifact, which I did) and then the p wave and the sinus beat, etc ad nauseum until the sinus beat kicks in for a while.

    So there were either one or two p waves not related to a darn other thing, and one that was related to a beat. That made me really, really confused. No dig level, no digoxin as a home med. BP was running 130's over 80's. I did an admit assessment but did not have her as a patient. Basically I had to go look at her after seeing that rythym and so I found an excuse. The ekg was done during a sinus period and had a 1mm ST elevation which I also found, so it read okay. And no I didn't keep copies of strips because it's so interesting, I am fairly certain my boss will keep some, with name blocked out, for education purposes.

    Basically when I looked at p waves, first I see them before sinus beats. So I'm thinking screwylooking bigeminy. Then I realize half the pvc's are smaller than the other half and they almost look like escape beats or fusion beats. I'm suspicious of pvc's on such a low heart rate (40's when it was doing the funky mess) anyway. Then I get the calipers and say, ok what the heck, lets pretend there are p waves elsewhere. This is how I find my heart blocks, is I decide to pretend it is this, then try that, then finally I may find my answer. Did I say I hate heart blocks? Well I do.

    So I find some things other than the obvious p waves which may be p waves, and if they are then the pt is in some real trouble. Those consist of notches in the t waves of the pvc's and some other blips in the artifact on the isoelectric line between the paired beats. And this stuff that I may be hallucinating, marches out very regular and is the same p to p interval that shows up in the pt's runs of normal sinus rythym. And yes, the pvc's were all unifocal even if they varied in size.

    The ER doc looked at last year's ekg and decided that the problem has been developing gradually over the last year, which is why the cardiologist she saw previously didn't work her up for anything except sleep apnea.
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    Without a visual, it's hard to wrap my mind around it, but, I'll have a go at it. It doesn't sound too much like 3d degree HB, the 2nd beat shouldn't be a PVC. Sound like a sinus beat followed by an aberrantly conducted PAC. Then you get a compensatory pause, and the cycle repeats...almost like atrial bigeminy. Kind of wonder is you're looking for zebras in the pause, seeing p-waves wehre there really isn't any. The other idea I had was a 2nd degree, Type II, with a 2:1 ratio, but with the second beat in the pair being early, it doesn't fit the textbook.

    Just me thinking out loud. I second the above comment about a 12-lead, it could be helpful to figure out what's up.

    Tom
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    This is very strange an has definately caught my interest now. If I had an ECG of it Im sure we could figure it out. A notched T wave can represent many things. One of the common things it represents is Left Ventricular Hypertrophy. Alcoholics also show notched T waves sometimes. As far as the rhythm from what I can visualize Im either thinking its second degree type II with ectopic beats of some origin or Type III with ectopics. Slow rate, dropped beats, some P waves without a QRS to follow, PVC's with notched T waves and pauses. My guess is progressive heart block with ectopics. The unifocal PVC's of varying size indicate to me an axis deviation that is changing back and forth. However I wonder what the significance of the 1 mm elevation is. Please post this when you get a chance. I would love to see the actual 12 lead if you can get it
    BBFRN likes this.
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    Welp, I'm not back to work yet, will see what updates I get tonight. However, I didn't post history on the patient because 1- I'd like to wait for updates and 2- make sure I'm not being too specific due to coworkers who read the board. Small hospital, very interesting case, not too hard to figure out who the patient is.

    Will post tomorrow!
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    I got no update, but I put my boss on the assignment. Will just have to wait on an explanation.
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    Hi Indy:

    You need more data. What happens with the P wave at the pause,
    if it remains normal it sounds like normal sinus bradycardia with a RBBB and
    escape beats. The question is why so slow? Is there SA disease? What about your PMH? Meds? etc. Prior CAD could be the cause for the RBB and
    perhaps Sick sinus syndrome. Is there any other variation other than brady
    with ectopy? Is there hypotension associated with the bradycardia. Do the
    ectopic beats perfuse? (pulse with ectopy)

    Inquisitivewon
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    Could be a high grade AV block (not 3rd degree) with escape beats or you could've had a sinus block or sinus arrest with escape beats. Its hard to say bc I can't see the strip. Look those up I listed and see if it favors.


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