Rythym question

Specialties CCU

Published

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.

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.

Specializes in ICU, telemetry, LTAC.

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!

Specializes in CCRN-CMC-CSC: CTICU, MICU, SICU, TRAUMA.

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?

Specializes in ICU, telemetry, LTAC.

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

Specializes in CCRN-CMC-CSC: CTICU, MICU, SICU, TRAUMA.

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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