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Rythym question

Specializes in ICU, telemetry, LTAC. Has 5 years experience.

Ok folks I'm stumped. I monitored a pt who I'd have liked to have in my unit, not on the floor on tele, and who had a rythym I've never seen the likes of before. I'll describe it, and y'all tell me if you've seen this. Occasionally she's sinus, PRI of .15 or .16, brady in 50s with a right bundle block, no big deal. Then there's a pause, sometimes 1 sec, sometimes long enough to make the monitor go nuts, then we get paired beats. The pairs are such that the first one in the pair has a PRI of about .16 and it looks just like the sinus beats did. The second one in the pair is a pvc. It should just be bigeminy but the pvc's vary in size, still unifocal, and some of them look like little escape beats. The distance between the pairs is fairly consistent, but longer than I would like for a compensatory pause to be. I'm used to bigeminy looking like almost equal distance between most of the beats, it doesn't bunch up into pairs.

I ran a deskfull of strips on this lady, got my eyeballs to vibrating eventually and I am convinced this is 3rd degree block with the p waves hidden in the T after each pvc. It just takes being either really picky or truly hallucinating to find 'em. I can't decide which I was doing. I did try looking this stuff up, I can't find examples of anything that looks like this.

And the troponin was up, there was a little ST elevation, maybe 1 mm.

BBFRN, BSN, PhD

Specializes in Trauma,ER,CCU/OHU/Nsg Ed/Nsg Research. Has 15 years experience.

Have you had an EKG done on the patient?

joeyzstj, LPN

Specializes in CVICU, ICU, RRT, CVPACU.

A few questions, and maybe Im reading what you are trying to say wrong, but how were you getting a PRI with the P buried in the T? I have actually seen something similar to this which I thought was third degree heart block with BB and ended up being some type of rarely seen Slow afib with a BBB. Did you happen to check a dig level on this patient? Im still a bit confused. Were you able to see ANY P waves? The unifocal PVC's, were of varying size, but still unifocal correct? I would love to see a stip of this if you could scan it. If you mark out the stip name you should be able to post it. One last question, what was the patients Blood Pressure with this rhythm?

Indy, LPN, LVN

Specializes in ICU, telemetry, LTAC. Has 5 years experience.

A few questions, and maybe Im reading what you are trying to say wrong, but how were you getting a PRI with the P buried in the T? I have actually seen something similar to this which I thought was third degree heart block with BB and ended up being some type of rarely seen Slow afib with a BBB. Did you happen to check a dig level on this patient? Im still a bit confused. Were you able to see ANY P waves? The unifocal PVC's, were of varying size, but still unifocal correct? I would love to see a stip of this if you could scan it. If you mark out the stip name you should be able to post it. One last question, what was the patients Blood Pressure with this rhythm?

Okay, let me clarify. And I don't go back to work till tuesday, so I won't have any kind of update until then. We'd have, a p wave, PRI of 0.15 to 0.16, then immediately after, a pvc, with a notch in the t wave of that pvc, then something about 1 second, sometimes longer, of isoelectric line with fine artifact that you could just BARELY make out a p wave in the middle of, (no complex following and that is if you think that's a p wave in the artifact, which I did) and then the p wave and the sinus beat, etc ad nauseum until the sinus beat kicks in for a while.

So there were either one or two p waves not related to a darn other thing, and one that was related to a beat. That made me really, really confused. No dig level, no digoxin as a home med. BP was running 130's over 80's. I did an admit assessment but did not have her as a patient. Basically I had to go look at her after seeing that rythym and so I found an excuse. The ekg was done during a sinus period and had a 1mm ST elevation which I also found, so it read okay. And no I didn't keep copies of strips because it's so interesting, I am fairly certain my boss will keep some, with name blocked out, for education purposes.

Basically when I looked at p waves, first I see them before sinus beats. So I'm thinking screwylooking bigeminy. Then I realize half the pvc's are smaller than the other half and they almost look like escape beats or fusion beats. I'm suspicious of pvc's on such a low heart rate (40's when it was doing the funky mess) anyway. Then I get the calipers and say, ok what the heck, lets pretend there are p waves elsewhere. This is how I find my heart blocks, is I decide to pretend it is this, then try that, then finally I may find my answer. Did I say I hate heart blocks? Well I do.

So I find some things other than the obvious p waves which may be p waves, and if they are then the pt is in some real trouble. Those consist of notches in the t waves of the pvc's and some other blips in the artifact on the isoelectric line between the paired beats. And this stuff that I may be hallucinating, marches out very regular and is the same p to p interval that shows up in the pt's runs of normal sinus rythym. And yes, the pvc's were all unifocal even if they varied in size.

The ER doc looked at last year's ekg and decided that the problem has been developing gradually over the last year, which is why the cardiologist she saw previously didn't work her up for anything except sleep apnea.

Spatialized

Specializes in Cardiac Telemetry/PCU, SNF. Has 5+ years experience.

Without a visual, it's hard to wrap my mind around it, but, I'll have a go at it. It doesn't sound too much like 3d degree HB, the 2nd beat shouldn't be a PVC. Sound like a sinus beat followed by an aberrantly conducted PAC. Then you get a compensatory pause, and the cycle repeats...almost like atrial bigeminy. Kind of wonder is you're looking for zebras in the pause, seeing p-waves wehre there really isn't any. The other idea I had was a 2nd degree, Type II, with a 2:1 ratio, but with the second beat in the pair being early, it doesn't fit the textbook.

Just me thinking out loud. I second the above comment about a 12-lead, it could be helpful to figure out what's up.

Tom

joeyzstj, LPN

Specializes in CVICU, ICU, RRT, CVPACU.

This is very strange an has definately caught my interest now. If I had an ECG of it Im sure we could figure it out. A notched T wave can represent many things. One of the common things it represents is Left Ventricular Hypertrophy. Alcoholics also show notched T waves sometimes. As far as the rhythm from what I can visualize Im either thinking its second degree type II with ectopic beats of some origin or Type III with ectopics. Slow rate, dropped beats, some P waves without a QRS to follow, PVC's with notched T waves and pauses. My guess is progressive heart block with ectopics. The unifocal PVC's of varying size indicate to me an axis deviation that is changing back and forth. However I wonder what the significance of the 1 mm elevation is. Please post this when you get a chance. I would love to see the actual 12 lead if you can get it

Indy, LPN, LVN

Specializes in ICU, telemetry, LTAC. Has 5 years experience.

Welp, I'm not back to work yet, will see what updates I get tonight. However, I didn't post history on the patient because 1- I'd like to wait for updates and 2- make sure I'm not being too specific due to coworkers who read the board. Small hospital, very interesting case, not too hard to figure out who the patient is.

Will post tomorrow!

Indy, LPN, LVN

Specializes in ICU, telemetry, LTAC. Has 5 years experience.

I got no update, but I put my boss on the assignment. Will just have to wait on an explanation. :(

Inquisitivewon

Specializes in Med-Surg., Critical Care, Cath. Lab., OR. Has 25 years experience.

Hi Indy:

You need more data. What happens with the P wave at the pause,

if it remains normal it sounds like normal sinus bradycardia with a RBBB and

escape beats. The question is why so slow? Is there SA disease? What about your PMH? Meds? etc. Prior CAD could be the cause for the RBB and

perhaps Sick sinus syndrome. Is there any other variation other than brady

with ectopy? Is there hypotension associated with the bradycardia. Do the

ectopic beats perfuse? (pulse with ectopy)

Inquisitivewon:cool:

Could be a high grade AV block (not 3rd degree) with escape beats or you could've had a sinus block or sinus arrest with escape beats. Its hard to say bc I can't see the strip. Look those up I listed and see if it favors.

Indy, LPN, LVN

Specializes in ICU, telemetry, LTAC. Has 5 years experience.

Well I got a look at the cardiac consult which said sick sinus syndrome for the particular bit that I was concerned with. My boss disagreed and said it was second degree block type two, with escape beats. You know, that 2nd degree type 2 is the one thing I try not to see. There shouldn't be any bias when reading strips I guess, but that's usually the last thing I'll think- I'll say third degree first. Hm.

History: female, forties, no smoking or drinking or drug use, myositis is the prominent history, also known as fibromyalgia syndrome. Previous to this arrythmia, she had psvt, pneumonia, flu, arthritis-like foot problems, and other stuff I don't readily remember on the history. Presented with elevated ck, elevated ck-mb and elevated troponin, but only 1mm ST elevations in the telemetry and ekg. The ekg only caught the sinus with bundle, not the second degree with ectopy so it was very little help to me.

Complained of chest pain relieved by nitro and morphine, also right upper quadrant pain with what felt like a firm liver to me. No firm diagnosis of the fibromyalgia or myositis so other than NSAIDS, not much specific to treat autoimmune type disorders. Oh, yes and I think the ectopic beats were perfusing, but irregularly so as the radial pulse I got was very irregular both in strength and rate.

She went home, did not have any other complications and I'll be interested to see how she does if she comes back to see us. I did find reference to some papers on myositis and heart block that did not seem to have a good outlook on the situation with that type of development, although it is a rare occurrance. My lesson learned is to keep a sharper eye out for my second degree blocks.

NoviceToExpert

Specializes in CCRN-CMC-CSC: CTICU, MICU, SICU, TRAUMA. Has 2 years experience.

I'd love to see this strip... post it if/when you get it...

If you have a consistent PR you can map without considering the PVCs then you can't have a third degree... you'd have a second degree... if the PRI is pretty consistent then a pause... it seems like you are on the verge of losing that AV conduction down through the bundle... can you describe more of what you are calling the PVC?... could it possibly be an escape beat (like you mentioned already) kicking in after a nonconducted p wave after a 2:1 block? Are there any inverted p waves from regtrograde conduction? Is the QRS "ectopic" beat isoelectrically opposite the p conducted QRS complexes? Are her lytes normal?

Next question... what happens between when the paired complexes end and the new sinus sequence begins?

Maybe it's just "ASB"....

..."attention seeking behavior"....

just kidding...

very intersting rhythm... the cardiologist didn't commit to calling it anything?

I'll check back on this thread, thanks for posting this!

Was the patient stable? What was the BP? Any vasopressors? A third degree block will not have the same PRI on the one consistent normal sinus beat that you mentioned that occurred just before the funny little beats (FLB's). You may be looking at things too closely or too hard. Sometimes an explanation is unrealistic, such as a heart rate of 20 to 30 on an alert, oriented old lady with a systolic bp of 180. I have seen that, which defies logic.

Indy, LPN, LVN

Specializes in ICU, telemetry, LTAC. Has 5 years experience.

The cardiologist called it sick sinus syndrome. BP 130's/80's. No vasopressors, and the pvc's were not all the same. All pointed the same direction, but some were big, "normal" looking things and some were rather squashed looking. The patient was stable, talkative, and had decent symptom relief by the time I saw her.

I don't get ready access to materials to copy once they've left my monitoring shift, so likelihood of posting is less than that of my house sprouting wings, unfortunately. You know how it is with education- bosses like it their way. I do still intend to have her chart pulled back out so I can get another good look, and I requested an actual inservice. :-) If I see the cardiologist when he's not in a huge hurry I will ask him as well.

Having turned it over a bit more in my brain, I see now that yes, I should have seen second degree block. Which is fine, but what messes with my head now is why the pvc's (what ever in this fine world you wanna call them) wind up in the spot they do. I'd even be okay with second degree with bigeminy if the darn things would just not be glued to the tail end of a sinus beat. I really think her block is progressive and it's gonna be third degree at some point in the not so far off future.

Well anyhow I've probably beaten this poor horse, er rythym, to death. Gotta sleep now!

NoviceToExpert

Specializes in CCRN-CMC-CSC: CTICU, MICU, SICU, TRAUMA. Has 2 years experience.

Sick sinus?!!! Yes to marked bradycardia, sinus pauses or periods of sinus arrest... but then sick sinus alternates that paroxysms of rapid atrial arrhythmias, especially atrial flutter or a-fib.... aka brady-tachy syndrome. During the periods of brady sometimes junctional escape rhythms commonly occur and AV block is also often associated with sick sinus (which is why I was asking about inverted p's related to retrograde conduction)... but hmmm... I didn't see anything about the rapid rhythms in the original post.... causes of sick sinus include inflammatory cardiac disease, cardiomyopathy, sclerodegenerative processes involving both the sinus and AV nodes, drugs like beta blockers, calcium channel blockers, dig, amio, propafenone and adenosine. Bummer about getting the strip posted... and I hear you about the education and management liking it that way...on my old unit I recently heard from an insider at a management meeting that they weren't going to orient all the nurses to recovering the post op CABGs because then they'd all have an advanced skill set and some of them would leave... geezzz.... just unbelievable isn't it?

Indy, LPN, LVN

Specializes in ICU, telemetry, LTAC. Has 5 years experience.

That's just silly... not like an advanced skill set would benefit patients, huh?

NoviceToExpert

Specializes in CCRN-CMC-CSC: CTICU, MICU, SICU, TRAUMA. Has 2 years experience.

Yupp, just nonsense... I couldn't believe it when I heard it... what they don't realize is that the good nurses elevate themselves wherever they are and if a unit or a hospital is an impediment to such they go elsewhere... leave anyway... and the problem isn't solved on administration's end in the outcome...good nurses will seek out the experiences they want and need...This is why my old unit is stocked with agency and travelers... no one in the hospital wants to work there...

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