rhythm question

[Hoosiernurse]

I'm relatively new nurse with critical care training and a new job on a tele floor. I had a patient who came in for syncope with collapse who bradied to 36 while in my care. I went to check on him, got vitals (all stable) and he had no symptoms. The monitor reader said he was already back up to 85 in the time it took to walk back to his room. My preceptor checked the strip and came to tell me it was a run of about 10 non-conducted PAC's in a row. I didn't even question that, I just wrote it down. When I gave this info to a more experienced nurse during report, she scoffed and huffed and puffed at me, saying, "That doesn't make any sense! PAC's are harmless!" I told her they were non-conducted, and that I thought maybe the pauses that can be associated with each PAC with no subsequent QRS complex might have accounted for it (I should have looked at the strip myself, in retrospect, instead of letting my preceptor make up my mind for me), but she was still huffing and rolling her eyes, telling me that just can't be and it made no sense. I wasn't in the mood, at the end of 12 hours, to argue with her, and don't feel I would have a strong argument anyway. I said, "Okay, you'll have to take a look at it yourself, that's the information I have." The patient had no repeat episodes and the doctor had been called regarding the issue. The patient received an AICD three days later. Heart cath (after the episode) revealed a partial blockage of LAD (they said this was not "tight" enough to open), and an EF of 20%.

Anyone out there with more experience in reading strips know if a 10 beat run of non-conducted PAC's can result in bradycardia? It's just bugging me.

Thanks.

[highlandlass1592, BSN, RN]

A third degree block is a complete dissociation between the sinus node and the ventricles. A single nonconducted P is not a third degree block. You can tell a third degree block because the P to P and R to R intervals remain constant, but are simply unrelated to one another.

Without seeing the strip, what the OP describes sounds more like a transient second degree type II. The reason the tele monitor would call it "bradycardia" is because machines are stupid. The tele monitor is simply tracking the ventricular rate, so when there are no ventricular beats, the telemon will either call it "bradycardia" or a "pause".:redbeathe

I loved that! Machines are definitely stupid, that's for sure!!!!

[Keysnurse2008]

i loved that! machines are definitely stupid, that's for sure!!!!

exactly! thats why in the ed we say " when in doubt...dont monitor your monitors....monitor your patient!":yeah:..gotta call 2 days ago from tele we had on a patient bound for a stepdown floor with a holter monitor on...saying the patient was in vtach....i went in the room and he was also on our ecg machine...and yep....it looked just like wide v tach....only problem was -respiratory was doing percussion on him. lol......when in doubt dont monitor your monitor...monitor your patient. learning ecg's just takes a little time...but it will all come to you. i hate that the oncoming nurse acted like an a**. knowledge is one of those things that should be shared. if they werent going to use that moment to teach you a point on ecgs then they should have kept their trap shut and just looked at the strip after you left. bc in a patient with an ejection fraction of 20% anything ...anything can happen. crazy arrythmias.....usually d/t long term htn or cardiomyopathy- aka big ole floppy quivering twitchy heart. you can pm me if you want me to give you a easy ecg interpretation that is easy to remember for the basic ones. it might help. but with an ef of 20...like i said...runs of pac's is not a stretch at all. with an ef of 20...heck...just be glad it was still a beatin.