junctional vs sinus bradycardia

[kaitef07]

Hey everyone so I was hoping someone could shed some light to me on the difference between junctional bradycardia and sinus bradycardia. So my patients hgb was 4.8 & plat was 18. I was instructed to give him 3 units of blood and 2 units platelets. Right after initiating the blood I called the MD and asked if he wanted him on tele since there was a question of gi bleed and our hospitals policy is tele for gi bleeds so he agreed. I got it hooked up towards the end of the first unit of blood and I noticed his heart rate was 37. The rest of his vitals were fine and the pt was asymptomatic. I notified the doctor and the ICU charge nurse and we continued to monitor the patient as i proceeded with the transfusions. I looked at the heart rhythm again and my opinion was he was in junctional bradycardia. There was absolutely no P wave. QRS measured 0.08 and the T was 0.44 I believe. I called the doctor since his heart rate was still in the 30s and asked if he thought he was appropriate for our floor. He agreed to send him to a higher level of care but upon transferring him the ICU was giving me problems saying he doesn't need to be here you guys can monitor arrhythmias on your floor and that isn't junctional that is sinus bradycardia so if someone could help me understand the difference between the two rhythms a little better that would be great. thanks.

[VANurse2010]

Based solely on your description, it sounds more like junctional brady. 4.8 Hgb on general medicine/tele unit is too low, combined with the bradycardia - the patient should have been in the ICU at least until a firm handle on the source and plan was decided.

[loveu123]

I have worked mainly in level 1 hospital and currently PRN in a level 2. This patient may not necessarily need to be in ICU and could be monitored in an IMC or some cardiac unit depending on your hospital policy. The rhythm you described is junctional rhythm.

[RescueNinjaKy]

Sinus Brady would have a p wave. It sounds like junction all rhythm to me. As long as he's asymptomatic and other vitals are good I wouldn't be too worried. He's getting blood to bring up his hgb, he's on tele for monitoring and also he's asymptomatic. Now if he was symptomatic or his other vitals weren't ok, then I wouldn't want him on the floor.

[Anna Flaxis, BSN, RN]

Did the patient have a history of AMI? ETOH? On BBs or CCBs?

What was the doctor looking at when he said it looked sinus? Was he reviewing your rhythm strips, a 12 lead, or the rhythm on the ICU monitor? Was there any change from what you saw when you initially identified the junctional rhythm?

It could be that this is not new for this patient, and that he lives like this. If this is the case, then he doesn't necessarily need an ICU bed, unless he is symptomatic. Tele monitoring should suffice.

An HGB of 4.8 should have bought him an ICU bed IMO, but what meets ICU criteria in your facility may differ from where I practice.

[kaitef07]

Thanks yeah 99% of the time a person at our hospital with labs that low will get a direct ticket to ICU. He initially was brought in for a cardiac cath but after doing his labs that certainly wasn't happening. His 12 lead from the day before actually showed sinus Brady and like an hour or so after I saw junctional I looked at the tele again and he was back in sinus Brady. I'm pretty confident in my skills as a nurse (not always with tele but I just got an ICU job somewhere else so I'm sure that will change) but no one even noticed any of these issues until I hooked him up to tele so I just think he truly lives there.

[Horseshoe, BSN, RN]

I was just going to suggest that perhaps he had converted to a sinus brady when the doc looked at him.

[RescueNinjaKy]

Thanks yeah 99% of the time a person at our hospital with labs that low will get a direct ticket to ICU. He initially was brought in for a cardiac cath but after doing his labs that certainly wasn't happening. His 12 lead from the day before actually showed sinus Brady and like an hour or so after I saw junctional I looked at the tele again and he was back in sinus Brady. I'm pretty confident in my skills as a nurse (not always with tele but I just got an ICU job somewhere else so I'm sure that will change) but no one even noticed any of these issues until I hooked him up to tele so I just think he truly lives there.

Does your facility save their strips on tele. You could always pull them up for the doctor to see. Also in my facility they should have an area that lets them see the strips on the emr.

[ProgressiveActivist, BSN, RN]

The pt kaitie had could turn on a dime.

He did come in originally for a scheduled ♡cath.

At that point he had an univestigated severe anemia and suspected but uninvestigated CAD.

People flip in and out of arrhythmias depending on their activity level or for no apparent reason. Being in junctional puts him at risk of going into 3rd degree block.

She did just fine.

She could have simply told the staff -wait five minutes it will change.

[Anna Flaxis, BSN, RN]

I don't think anybody is questioning that the OP did fine, but keep in mind that criteria for ICU admission does vary from facility to facility. A patient that qualifies for ICU at my facility may be a tele patient at another.

[ProgressiveActivist, BSN, RN]

Keep in mind that I understood you the first time you said it.

[ixchel]

It's somewhat common for p waves to hide on tele alone depending on lead placement and patient habitus. The QRS allows you to know its not a ventricular rhythm, but beyond that, I think a 12-lead would be needed.

My hospital would use step down for this patient if they are asymptomatic without obvious signs of bleeding. ICU if symptomatic, or if the MD for that patient just prefers it.