[Dinith88]

Originally Posted by VicChic

PAC's in Afib? Of course not. PAC's with Afib. Yes, as was stated earlier by myself and a few others, you can have Afib with runs of PAC's or just frequent PAC's. There's is a difference b/c in Afib=no p wave=obviously not an atrial contraction of any sort. PAC's [u]with[u] Afib=a p wave occured from somewhere= there's atrial electrical impulses from somewhere trying to be recognized once again. So yes the underlying rhythm may be Afib, but once you see a p wave present (and it's probably best to be in lead II for this particular rhythm interpretation) you no longer can call this Afib. It has to be Atrial Contraction and obviously premature since the underlying rhythm is still irregular. Where I've worked this is seen all too often. Remember, afib doesn't always necessarily mean the atria are incapable of emitting electrical activity; the only thing that is definite is the interruption of a normal conduction of the heart's electrical activity, which should originate from the SA node but doesn't. Sometimes with a chronic Afib'er, you put them on Amiodorone, Cardizem, or some other antiarrhythmic and/or Digoxin, and then you see more PAC's then ever b/c you've now broken up that incorrect pathway of electrical impulses that heart was using and rate control has now allowed SA node to get back to being the impulse generator again. Seen all the time in nuc med with stress test, and in CCU, and often seen by paramedics in the field if a person has just been in a lot of trauma.

VicChic, you're stretching. Next time you're at work ask a cardiologist.

[VicChic]

Not stretching, just explaining what I, along with others in cardiac nursing/cardiology already know and accept to be fact. Sorry you don't comprehend but you are in good company. After all, it's a cardiologist that had to explain it to me FYI. I had to learn it myself and now I'm sharing it with someone else, because they were smart enough to ask and then smart enough to listen. You're right, you should ask a experienced cardiologist.... so they can turn around and tell you the same thing. Have a blessed day!

I just want to applaud the OP for using their resources to investigate such a thought-provoking question that obviously showed good critical thinking b/c they thought deeper than just "textbook" explanations. Once again, that's a beautiful skill in nursing that Harley Fan has obviously mastered. It's the funky stuff that keeps it interesting so keep on keeping on! Embrace it and have fun with it. Keep an open mind so your mind can absorb information that's new to you, and most of all keep that teachable attitude. You can't lose with that! Buh-Bye!

[telehead]

Originally Posted by VicChic

Not stretching, just explaining what I, along with others in cardiac nursing/cardiology already know and accept to be fact. Sorry you don't comprehend but you are in good company. After all, it's a cardiologist that had to explain it to me FYI. :wink2: I had to learn it myself and now I'm sharing it with someone else, because they were smart enough to ask and then smart enough to listen. You're right, you should ask a experienced cardiologist.... so they can turn around and tell you the same thing. Have a blessed day!

I'm torn between responding or allowing this dead horse to lie... But discussion is fun. :)

With all due respect, I believe you have either interpreted what your cardiologist said incorrectly or taken the question to him/her in a vague manner. It was your previous response that leads me to believe this:

PAC's in Afib? Of course not. PAC's with Afib. Yes, as was stated earlier by myself and a few others, you can have Afib with runs of PAC's or just frequent PAC's. There's is a difference b/c in Afib=no p wave=obviously not an atrial contraction of any sort. PAC's [u]with[u] Afib=a p wave occured from somewhere= there's atrial electrical impulses from somewhere trying to be recognized once again. So yes the underlying rhythm may be Afib, but once you see a p wave present (and it's probably best to be in lead II for this particular rhythm interpretation) you no longer can call this Afib. It has to be Atrial Contraction and obviously premature since the underlying rhythm is still irregular.

This is, I believe, tho I don't want to speak for Dinith88, the stretch Dinith88 was referring to earlier and where I believe your argument falls into vague/lack of comprehension mode (lack of comprehension by me may also be the answer). "It depends on what the definition of 'is' is."

I contend your use of with and in is simply semantics which raise a straw man in the discussion. By stating a difference between with and in as you've done, you've actually created two different rhythms. Your statement that "in Afib=no p wave=obviously not an atrial contraction of any sort." is precisely what many of us have been saying all along and it is the answer to the question originally posed. The strawman appears when you tried to change that to with afib. You present a definition that places the presence of p-waves as part of afib when it's actually only possible once the rhythm changes from afib to anything else, as I believe you (inadvertantly?) state here: So yes the underlying rhythm may be Afib, but once you see a p wave present (and it's probably best to be in lead II for this particular rhythm interpretation) you no longer can call this Afib. It has to be Atrial Contraction and obviously premature since the underlying rhythm is still irregular.

The bold section, I agree with but I am unable to reconcile your statements in the first part- "may be afib" with the second part- "no longer can call this afib".

The last part, I don't agree with either. If the underlying rhythm is still irregular, but p-waves are still present, then you don't have afib, under/over/between or otherwise-lying. If it's irregular, then you have sinus arrhythmia or you have sinus with frequent pac's.

It comes down to this- a p wave on a strip indicates depolarization of the atria. The "quivering" of the atria occurs because there are multiple points in the atria (irritability) firing randomly, thus preventing the atria from fully depolarizing (or repolarizing). The atria hang, electrically, in the threshold region. The AV node, with its much slower calcium channel conduction system, allows much fewer atrial impulses through than are created. This is why you see irregularity. The first impulse that gets through might come from point A but the second one may come from point B or point C. Now when you consider the irritable atria may have 100 (randomly chosen number) points of electrical impulse origin, you can see why the resulting rhythm is irregular. What you don't ever have during this time is a fully depolarized atria and thus no full atrial contraction, therefor, you don't ever have a mature or premature atrial contraction during afib.

That's my story and I'm sticking to it.... unless someone can change my mind.

[Spidey's mom]

See? (Refer to my earlier post about the ever-changing interpretations of heart rhythms).

Y'all keep talking though - I'm learning, just not sure what.

steph

[PICC ACE]

"but once you see a p wave present (and it's probably best to be in lead II for this particular rhythm interpretation) you no longer can call this Afib.....you put them on Amiodorone, Cardizem, or some other antiarrhythmic and/or Digoxin, and then you see more PAC's then ever b/c you've now broken up that incorrect pathway of electrical impulses that heart was using and rate control has now allowed SA node to get back to being the impulse generator again"
It sounds to me that what you are describing is a SINUS beat--p-wave followed by a QRS--occurring during a predominance of AFib. This,granted,is seen frequently enough. I have never heard anyone refer to these as PAC's.

[VicChic]

You guys, I know you all are way too smart to let this one go over your head. All I'm doing is simply presenting a scenario to you. The question was asked if you could have PAC'S with Afib. The answer to that question is simply YES, you can as the original responder put it. I guess my only mistake was going into further detail. I keep forgetting everybody doesn't alway benefit from the who, what, when, where, and WHY. But I LOVE knowing WHY. It helps me to understand. All I'm trying to do is explain why, so there can be a full understanding of the reason the answer is simply "yes."

So there's another confusion about this? Okay. I thought I had explained it simple enough but....here goes. Once again, if the patient is in A-fib (ok, take that in for a sec) and then you see PAC's, not actually a part of the Afib b/c .....you have atrial contractions--- "How can you tell," you ask. PAC's with Afib are usually frequent enough to tell that the p wave is not just another quiver of the A fib b/c that atrial contraction is originating from the same foci so the p waves should look identical to each other. And to quote myself before someone else does so there's no confusion left hopefully (LOL), "PAC's are usually frequent enough to tell that the p wave is not just another quiver of the A fib" due to the pathophysiology like what I was explaining earlier about the heart's attempt to convert back into sinus. (See earlier posts) Now that we've establish that, this contraction IS NOT Afib--it can't be...there's a P WAVE involved. Still with me? Now... it's presumptuous to call it a "SINUS" beat b/c there would have to be a ventricular contraction to follow IMMEDIATELY after the p wave, because as you know, sinus beats are composed of both p waves and QRS complexes. A sinus beat is not what I interpreted out of the original post, only Afib and PAC's were mentioned. And that's the reason why those beats would not meet the criteria to be called sinus--simply put, no ventricular contraction, only a premature atrial contraction, which is why the nurse called it "Afib with PAC's."

So in a nutshell, you got Afib, then a few definite, true p waves->No longer just Afib---they are not followed by QRS complexes-->Cannot be sinus. So what do you all call this if it's not Afib with PAC's b/c ever since I learned rhythm interpretation that's what I've called them, that's what other nurses have called them, and the cardiologist.

Now I've answered alot of you guys' question, so how about answering one for me? Where are all of you working at and/or where have you worked and what is your discipline? This helps me to understand why this is such a hard concept to understand. B/c I find it hard to believe anyone working cardiology, or tele, or ER (or anywhere where telemetry is used) is struggling with this. Afib with PAC's is not your everyday kind of rhythm, but it's not so rare that it causes this kind of confusion normally, so I'm just trying to get some understanding so I can better relate. And then again, I can't help but feel there may be understanding of all of this that I am saying, but it's just more fun to watch just how far can we kick a dead horse b/c I'm at the point of ad nauseum (LOL) j/k. If you have anymore questions, please ask; that's how you learn. But if your intent is to be facetious, please I ask, go to the Nursing Humor Forum. My intent is to genuinely address the OP's question, and hopefully facilitate learning. Thank You.

[jnette]

While we're on this Afib subject, mind if I ask a quick question? I'm not a cardiac nurse and I really don't know all the ins and outs of this stuff... and like Steph, I agree that it can get confusing at times.

I have a HH patient with a hx. of severe mitral insufficiency, Afib, and CHF.... in the past she had been on digoxin, but the doc had dc'd this early this year. She's still on Coreg, and Atacand.

The thing is, she is in a constant state of hypoxia... can never get an 02 sat above the low to mid 80's... often it's in the seventies... and this while on continuous 02 NC @ 2 L/min. I have to massage her arms and fingers for about 1/2 hour before I can FINALLY get a sat up to 90%. I've reported this to her doc time and again, but never get anywhere....

So my question is should she be on digoxin? Would it not benefit her in producing stronger contractions and thereby also raising those 02 sats?

Any reason she should NOT be on the dig?

I know this is kinda off topic, but I thought I'd ask, since we're somewhat on this subject. Any responses would sure be appreciated... this little lady means the world to me, and I'm trying to understand her doc's thinking here. (or my lack of understanding.. either way)

Thanx in advance.

[AndyB]

Originally Posted by jnette

The thing is, she is in a constant state of hypoxia... can never get an 02 sat above the low to mid 80's... often it's in the seventies... and this while on continuous 02 NC @ 2 L/min. I have to massage her arms and fingers for about 1/2 hour before I can FINALLY get a sat up to 90%. I've reported this to her doc time and again, but never get anywhere....

So my question is should she be on digoxin? Would it not benefit her in producing stronger contractions and thereby also raising those 02 sats?

Any recent ABGs?

[AndyB]

Would not you need at least three consecutive complexes with a p-wave to say that a person has a pac?

[jnette]

Originally Posted by AndyB

Any recent ABGs?

Not that I'm aware of, Andy. I do have an RT referral to hopefully do an overnoc reading... see what happens there. I need something to light a fire under her PCP's butt.