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.

[RescueNinjaKy]

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.

When I got floated to do tele tech on my unit, I've been able to see p waves on bradycardia. Don't know if this is just my facility, but if the rhythm is unclear and it looks crappy on the monitors then I switch the leads that's being displayed. If there isn't a good one then I go check the leads on the patient. I get if the rhythm is going fast and the p waves are obscured. But I don't really see that happening in Brady. I don't get floated to work the monitors often so I could totally be wrong.

[ixchel]

When I got floated to do tele tech on my unit, I've been able to see p waves on bradycardia. Don't know if this is just my facility, but if the rhythm is unclear and it looks crappy on the monitors then I switch the leads that's being displayed. If there isn't a good one then I go check the leads on the patient. I get if the rhythm is going fast and the p waves are obscured. But I don't really see that happening in Brady. I don't get floated to work the monitors often so I could totally be wrong.

I promise it can be common, and is usually due to lead placement or body habitus. It usually has nothing to do with whether a p-wave exists or not. Your approach to finding the p-wave in that situation is spot on.

[Guest219794]

Honestly don't even get the question.

You reported your findings to the Doc, he ordered a transfer, you transferred the patient.

Whether he was in a sinus rhythm on arrival to the unit is irrelevant.