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.