[Tweety]

Jnette, do you know the reason why this patient was taken off of Dig? Perhaps there were some unpleasant side effects or it wasn't working well. There probably is a reason.

However, it seems to me your patient would benefit from the dig, not only for the afib, but the mitral valve problem.

The concern is that if you have to warm up the body by rubbing the hands etc. your sats aren't all that accurate. But being home health what can you do? As stated above an ABG would be interesting to get.

Perhaps the MD should consider a diuretic, which would help with the CHF, and decrease the work on the heart and relieve any pulmonary congestion cause by the mitral valve problems.

[AndyB]

Originally Posted by jnette

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.

Just wondering if it is a ventilation problem or a perfusion problem. Low cardiac output versus hypoxia. Any recent LVEF%? Pardon my curiosity. I have also had low pulse ox readings due to vasoconstriction at the pulse ox probe site.

[jnette]

Originally Posted by AndyB

Just wondering if it is a ventilation problem or a perfusion problem. Low cardiac output versus hypoxia. Any recent LVEF%? Pardon my curiosity. I have also had low pulse ox readings due to vasoconstriction at the pulse ox probe site.

That's what I'm interested in finding out as well... I can't answer your questions, as I really don't know. I was wondering if the hypoxia was due to perfusion (or lack thereof) with her hx. of Afib, CHF, severe mitral insuff.

To me, it would seem that it would be a perfusion issue, but hey, what do I know?

[jnette]

Originally Posted by Tweety

Jnette, do you know the reason why this patient was taken off of Dig? Perhaps there were some unpleasant side effects or it wasn't working well. There probably is a reason.

However, it seems to me your patient would benefit from the dig, not only for the afib, but the mitral valve problem.

The concern is that if you have to warm up the body by rubbing the hands etc. your sats aren't all that accurate. But being home health what can you do? As stated above an ABG would be interesting to get.

Perhaps the MD should consider a diuretic, which would help with the CHF, and decrease the work on the heart and relieve any pulmonary congestion cause by the mitral valve problems.

Thanx, Tweets... she IS on Lasix for the CHF. And yes, I fully understand that having to rub her hands, etc. is NOT giving me an accurate reading at all. But I cannot leave her until I get a reading above 90%, and I have continuously reported this to her PCP.. all I get form him is to have her wear her 02 24/7 which she is already doing.

I will suggest an ABG and see what he says, along with the RT referral and overnight sat readings maybe we will get somewhere. I don't understand why everyone else is having to persue this instead of her PCP ????

I thought that was HIS job! I'd like to know her ejection fraction as well... you'd think HE would? What's up with these docs, anyway?
I'm sure she has had several cardiac work ups in the past before I started on with HH and got to know this pt., but ever since I have had her (over 2 mos. now) this has been an issue... but in the beginning I could still get a halfway decent 02 Sat on her... this past month, however, they have really been dropping, and she's c/o more frequent epidodes of SOB.

And it's such a shame, because this little woman at her age is so FULL of spunk, and life, and wit, she thoroughly enjoys life... she so enjoys being active and doing things around the house, yard, etc. I hate to see her cheated out of managable "relative" good health if there is something that can be done to addresse this.

I'm curious as to why she was taken off the dig as well... she told me she did well on it, she's the one who asked me if she shouldn't be back on it?

I hate to get in the doc's face about anything unless I know what I'm talking about, and as you can see.. I don't. That's why I'm asking these things...

[Tweety]

Jnette, also understand that there are going to be people who have chronic hypoxia and that's just the way they live life. Their bodies have adjusted and while not healthy, they maintain. Many people have O2 sats in the upper 80s chronically, especially with activity.

If the MD is o.k. with the hypoxia he should change the orders to allow for sats in the 80s, rather than you wasting your time trying to get her above 90.

Definately suggest an ABG. While ABGs just to get a pulse ox isn't appropriate all the time, in this case I would be very curious.

I agree, that if something could be done to maintain more optimal health, it should be tried.

[TachyBrady]

Originally Posted by AndyB

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

I've worked in telemetry for 13 years and I agree with the previous posters who've said it is not possible to have PACs in A fib. One of the reasons is as Andy has indicated... you would have to have several sinus beats in a row in order to determine that one is premature. And in that case, you would have a sinus rhythm and not fib. When I asked one of our cardiologists, her reply was basically the same: Since A fib is a chaotic rhythm, you cannot call an apparent isolated sinus beat premature.

[AndyB]

I'm also wondering why this pt is on Coreg rather then a selective beta blocker

[telehead]

Originally Posted by 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.

You may choose to address these points or not address these points. No big deal. But to continue restating your points as if in a vacuum, condescension included, does not help you relate this concept to those of us who obviously "don't understand" as well as you.

At this point, I feel comfortable stating plainly that you are wrong on this concept. Since the first post, I've considered it often, considered your post, considered other posts and have come to the conclusion that your point that you can have pac's with/in/around/below/above or in a parallel dimension to afib is incorrect.

The simple appearance of a "p wave" (a faux p-wave because it only represents the last depolarization ((and very limited depolarization path)) of many that the AV node let thru) within irregular afib is not evidence of a premature atrial contraction. There are plenty of "p-waves" (the squiggly line between qrs complexes) that appear on a strip. They represent various attempts of the atria to depolarize in a singular fashion.. unfortunately, because the cardiac tissue is so irritable, it can't. Point A fires and can depolarize tissue over to point B but because point C also fired, the tissue around it hasn't repolarized yet meaning point A's wave can't travel any further... But D and E also fire at the same time, limiting how far the depolarization wave can travel for each of them as well. Those times that point A can depolarize all the way to point J before hitting presently depolarized tissue is when you get something that approaches physically looking like a p-wave in the midst of the squiggle.

A PAC (premature atrial contraction) is a depolarization initiated by a point other than the SA node. However, for this to be called a PAC and not MAT (multifocal atrial tachycardia) or WAP (wandering atrial pacemaker), it must occur as a single occurrence or multiple occurrences within the structure of a normal SA initiated rhythm. ie., SA...SA...SA..PAC...SA..PAC...SA...SA...

Additionally, to address another inaccurate point you made- there are no increases in pac's (since there are no pac's in afib) prior to conversion to NSR. As a matter of fact, I have never seen a conversion from afib to NSR that did not happen without a pause. That's necessary because the atria need a period of time to repolarize entirely. As such, there is no 'walk before you crawl' or 'reverse process' as you've described in a couple posts.

In light of my explanation and my comfort/confidence in my position, I'm still more than willing to consider POV's contrary to what I've said and willing to consider that I'm 100% wrong. Discussion promotes understanding. However, I won't continue to discuss this with someone who offers nothing but the same point over and over without any consideration of the contrarian points brought up and essentially says "I'm right because I'm right and you're just not getting it." I actually find that to be opposite the notion of facilitating learning that you expressed earlier...

[telehead]

Originally Posted by jnette

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....

Agree with the others who state you should get an ABG. I've had pt's with sats in the low-mid 80's on the finger that registered a 96% on the ear! It would be a good idea to know exactly what the sat really is.

The use of Coreg is said to be better for the CHF patient because it's not only a Beta-1 blocker but a beta-2 (bronchioles- breath easier) and alpha-1 (vascular arterioles- lower bp) blocker. From what I've read, it's preferred first line over digoxin with CHF patients... fib/flutter folks without the chf history still apparently respond to dig better.

[Dinith88]

Originally Posted by telehead

You may choose to address these points or not address these points. No big deal. But to continue restating your points as if in a vacuum, condescension included, does not help you relate this concept to those of us who obviously "don't understand" as well as you.

At this point, I feel comfortable stating plainly that you are wrong on this concept. Since the first post, I've considered it often, considered your post, considered other posts and have come to the conclusion that your point that you can have pac's with/in/around/below/above or in a parallel dimension to afib is incorrect.

The simple appearance of a "p wave" (a faux p-wave because it only represents the last depolarization ((and very limited depolarization path)) of many that the AV node let thru) within irregular afib is not evidence of a premature atrial contraction. There are plenty of "p-waves" (the squiggly line between qrs complexes) that appear on a strip. They represent various attempts of the atria to depolarize in a singular fashion.. unfortunately, because the cardiac tissue is so irritable, it can't. Point A fires and can depolarize tissue over to point B but because point C also fired, the tissue around it hasn't repolarized yet meaning point A's wave can't travel any further... But D and E also fire at the same time, limiting how far the depolarization wave can travel for each of them as well. Those times that point A can depolarize all the way to point J before hitting presently depolarized tissue is when you get something that approaches physically looking like a p-wave in the midst of the squiggle.

A PAC (premature atrial contraction) is a depolarization initiated by a point other than the SA node. However, for this to be called a PAC and not MAT (multifocal atrial tachycardia) or WAP (wandering atrial pacemaker), it must occur as a single occurrence or multiple occurrences within the structure of a normal SA initiated rhythm. ie., SA...SA...SA..PAC...SA..PAC...SA...SA...

Additionally, to address another inaccurate point you made- there are no increases in pac's (since there are no pac's in afib) prior to conversion to NSR. As a matter of fact, I have never seen a conversion from afib to NSR that did not happen with a pause. That's necessary because the atria need a period of time to repolarize entirely. As such, there is no 'walk before you crawl' or 'reverse process' as you've described in a couple posts.

In light of my explanation and my comfort/confidence in my position, I'm still more than willing to consider POV's contrary to what I've said and willing to consider that I'm 100% wrong. Discussion promotes understanding. However, I won't continue to discuss this with someone who offers nothing but the same point over and over without any consideration of the contrarian points brought up and essentially says "I'm right because I'm right and you're just not getting it." I actually find that to be opposite the notion of facilitating learning that you expressed earlier...

Telehead, you're spot-on.
VicChic, your id says you're 22yrs old. if this is true, you're obviously new to the profession...and to telemetry. You're very eager and are obviously intelligent. You'll soon learn that trying to argue-down experienced cardiac nurses (like telehead) with nothing more than 'you dont get it...i'm right'...wont work. This may sound harsh, but lots of people/nurses/student nurses read these threads and it's important that we dont confuse them with mis-information. i would re-read teleheads post. She is right. even if you still think anyone who (correctly)disagrees with you 'doesnt get it'.