Which Strips Are MOST Dangerous?

[pagandeva2000, LPN]

I may be considered to be a per diem monitor nurse for telemetry; a woman from staff ed wishes to recommend me. I took a wonderful EKG class last year, have books to refer to, but have not read the EKGs often enough at this time.

Which are the MOST dangerous ones? I know v-fib, v-tach, asystole, couplets, bigeminys...but are there others? What do the monitors look like? I plan to practice with my EKG CD ROMs over the weekend to try and simulate an experience.

Any help would be appreciated!

[PMHNP10]

I'm not an expert, but the AV blocks (in particular. a 3rd degree [complete heart] AV block) can be really bad.

[billythekid]

also watch closely for strips with R-on-T phenomenon, which precipitates VF!

[jessiern, BSN, RN]

Anytime you see a change on the monitor from the patients norm, the doctor should be notified. Some people live with AV blocks, bigeminy, ect. So your not going to do jumping jacks because you see a patient has a first degree AV block, but he's first degree develops into a 3rd, you might want to get a bit excited

Just make sure they are going to give you a lot of time learning with some that learns what they are doing. It will take you (and me) both a long time to be comfortable reading strips.

[meandragonbrett]

3rd degree AV, Torsades, PSVT, Afib, Aflutter, Junctional rhythms, etc. Good luck!

[GilaRRT]

Rather subjective question. Obviously, ventricular tachycardia, ventricular fibrillation, asystole, and PEA known as the "lethal rhythms."

However, the presence of other conduction abnormalities can provide us with much information about the possible clinical course of out patient:

-Patients who are having an MI have four times the mortality rate if they develop a hemiblock.

-Anytime we prolonge the QTc, we place the patient at risk for developing a lethal rhythm.

-STEMI, development of pathologic Q waves, and ST depression is generally considered bad.

-New onset LBBB with AMI is generally considered bad.

-If the QRS complex is wider that 170-180 ms, then you can assume an altered ejction fraction.

-Pathologic axis deviation is generally considered bad.

[Christie RN2006]

Anytime you see a change on the monitor from the patients norm, the doctor should be notified. Some people live with AV blocks, bigeminy, ect. So your not going to do jumping jacks because you see a patient has a first degree AV block, but he's first degree develops into a 3rd, you might want to get a bit excited

Most of our docs say that bigeminy is a stable rhythm, so there is no need to call. I still will call if they go from being in NSR with occasional PVCs to being in bigeminy. We had someone last night that kept flipping in and out of it. We do not call for couplets either, it has to be a run of 3 or more or symptomatic before we call.

Like Jessie said, be watching for any changes from the patient's normal rhythm... for example, A.fib is a very common rhythm but if the patient flips from NSR to being in A.fib you need to call asap because the docs can do interventions immediately. Watch for widening QRS, P waves and T waves inverting and ST segments either elevating or depressing because those signal major changes with the heart.

Bad rhythms that could lead to a patient coding include: A.fib with RVR (basically A.fib that goes really fast), SVT, S. Tach over 120, S. Brady, a worsening block or 3rd degree block, and very frequent PVCs.

Deadly rhythms are V. Tach, V. Fib, Asystole, and PEA.

[sharona97, BSN, RN]

Most of our docs say that bigeminy is a stable rhythm, so there is no need to call. I still will call if they go from being in NSR with occasional PVCs to being in bigeminy. We had someone last night that kept flipping in and out of it. We do not call for couplets either, it has to be a run of 3 or more or symptomatic before we call.

Like Jessie said, be watching for any changes from the patient's normal rhythm... for example, A.fib is a very common rhythm but if the patient flips from NSR to being in A.fib you need to call asap because the docs can do interventions immediately. Watch for widening QRS, P waves and T waves inverting and ST segments either elevating or depressing because those signal major changes with the heart.

Bad rhythms that could lead to a patient coding include: A.fib with RVR (basically A.fib that goes really fast), SVT, S. Tach over 120, S. Brady, a worsening block or 3rd degree block, and very frequent PVCs.

Deadly rhythms are V. Tach, V. Fib, Asystole, and PEA.

I agree watch those A-fibs. Also wide or or narrow complexes, as diferent meds are used to treat. The phrase that has stuck with me is the tombstone rhythm!

I think it's great to keep updating and restudying, good for you.

[GilaRRT]

In addition any indication of WPW (delta waves) and the presence of atrial fibrillation can lead to deadly dysrhythmias.

[sissiesmama, ASN, RN]

:smiley_aa

Hey - all posters have given you excellent information. Just something else I was going to point out.

If in doubt, ask. Like we all learned in nsg school, the only stupid questions are the ones we don't ask.

And, I know you'll be at the monitors, just remember treat the patient not just the monitor. I would get the patient who was confused or just a _____ who would pull off a crucial lead out of boredom or even an occasional MD on rounds who would try to mess with the staff and jiggle leads or something.

Good luck! I hope you enjoy it!

Anne

[sharona97, BSN, RN]

It's so ever changing, the work loads and the monitoring. I really take my hat off to those who continue to advance in knowledge and skill.

It always helps when you have great co-workers too!

[pagandeva2000, LPN]

Do the monitors have alarms? I am hearing that if a rhythm is changing for the worst, that it turns from green to red, and alarms go off. I have not formally spoken to anyone yet, just the person who wants to fuse me in there. But, I am told that the nurse or tech has to watch 30 monitors. Is it that these dangerous strips are constantly going on, or will it be that we will start seeing an instant change?

What I have noted is that the strips in the textbooks are more easily identifiable than the actual ones on the monitors or strips. My textbooks say that it is best to place the monitors on Lead II, because it is easier to interpet. I was also told that if I don't pick up on a danger rhythm, that my license is on the line. I can understand that. I also want to get use of the skill I gained in learning EKGs. It looks so interesting, and I plan to pull out my textbooks this weekend to review the material again.

Any suggestions on how to effectively monitor say, 30 people? Thanks for all of the wonderful advice!