# What is the significance of P waves on top of T waves?



## 8jimi8

Wish i saved a strip...

Anyway, our most experienced monitor tech was calling me and calling me freaking out about the p waves this guy had, were firing on his t waves... And i was like.. what do you want to know? Its PACs he's been doing this all night.

But then she keeps on freaking out like I needed to give her more information.  For the life of me i couldn't figure what she was getting at.

It looked like a slow SVT around 85 b/min, although there were T waves (not often seen in svt)

so i've been searching around, anyone know of any significance of the P waves firing on the Ts?


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## lightsandsirens5

There is a T on P phenomenon that is indicative of alkalosis. It is caused by a prolonged Q-T causing the T wave to touch if not overlap the P wave. Usually only seen a tachy rhythms. Could this be it? I suppose a prolonged QT in a fast rhythm would cause the T to actually fall during the P instead if just butting up to it.

How about U waves?

How did it look like SVT at only 85? That would not be tachy really, would it? 

Either of those make sense?


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## 8jimi8

what i meant by it looking like a slow SVT was just that it was narrow complex qrs with a definite p wave.

The p waves were firing on the t waves after the peak voltage, in other words, the T wave would form and maybe .02 seconds after the peak, a complete p wave would form, the p waves did not rise any higher than the peak of the T, but they were definitely not U waves.

I cannot remember anything about the patient's hx, but it is possible that the patient was alkalotic.  


I'll see if the monitor tech saved the strip, its possible, she usually keeps some of the rare gems we see on our unit.  Thanks for the ideas!


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## Akulahawk

Long PR Interval or just PAC's? As far as big/bad/nasty things, I don't recall there being anything instantly nasty about P on T... If that strip is still around... that might be an interesting one to see if it's not your garden variety PAC...


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## mycrofft

*Physiologically and anatomically speaking...*

Your ventricular heart is trying to repolarize at the same time the atria are "firing", compressing blood into the ventricles.


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## Akulahawk

mycrofft said:


> Your ventricular heart is trying to repolarize at the same time the atria are "firing", compressing blood into the ventricles.


Yes, I can see that... however, I don't recall that being an instant big/bad/nasty event. I can see that perhaps over time, there'd be valve problems or other atrial issues kicking up...


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## lightsandsirens5

8jimi8 said:


> what i meant by it looking like a slow SVT was just that it was narrow complex qrs with a definite p wave.


 
So essentially a NSR?



> The p waves were firing on the t waves after the peak voltage, in other words, the T wave would form and maybe .02 seconds after the peak, a complete p wave would form, the p waves did not rise any higher than the peak of the T, but they were definitely not U waves.


 
Actually in the T wave? So it kinda looked like a T wave with two peaks?



> I cannot remember anything about the patient's hx, but it is possible that the patient was alkalotic.
> 
> 
> I'll see if the monitor tech saved the strip, its possible, she usually keeps some of the rare gems we see on our unit. Thanks for the ideas!


 
I'd love to see the strip if you can dig it up!


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## 8jimi8

Akulahawk said:


> Yes, I can see that... however, I don't recall that being an instant big/bad/nasty event. I can see that perhaps over time, there'd be valve problems or other atrial issues kicking up...


this is how I was feeling.  I wasn't worried because it looked like PACs to me and although he had a run of 11 and some other random ones.  Now that I think about it I think this was my female prisoner patient.  She stopped having  chest pain after I told her I would not give her ANY more norco because the doc wrote orders for a single 1 time 5/325.  She pretended thy she couldn't walk halfway through her exerise stress test, so they ordered an adenosine stress test and then canceled it the next day bc the dic said "she doesn't need it." then she asked me for a comb on the last day and after she ran it through her hair, she woke up the :censored::censored::censored::censored:ING NEST of LICE!!!  Those thing were as big as FIRE ANTS!!


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## themooingdawg

Yeah, i think P waves on T waves is essentially a part of the cardiac cell in the atrium firing faster before the ventricles can fully repolarize and usually results in a PAC and/or SVT


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## themooingdawg

was therea  QRS that followed after the T/P wave? can be a nonconducted pac


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## 8jimi8

rather than conjecture on what might have been on the strip...

(and being that i'm on vacation right now!)

i've called up to the hospital, i think there are a few copies of that strip still in circulation at the hospital... SOO...

i have left messages with the appropriate parties and hopefully i'll be able to produce said strip for your viewing pleasures...

i'm in tucson right now, be back late sunday.... maybe get ahold of it as early as tuesday, so stay tuned


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## lightsandsirens5

8jimi8 said:


> i'm in tucson right now, be back late sunday.... maybe get ahold of it as early as tuesday, so stay tuned



Lucky dawg! Betcha is warmer there than here! @$?&! 33* last night! I am ready for winter to end now, OK? God, can you hear me?! 

Ok, can't wait to see the monitor strip. Must be unique if it is circulating the hospital. Those hospital peoples don't usually get excited by that kinda stuff unless it is really good. :-D


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## 8jimi8

lightsandsirens5 said:


> Lucky dawg! Betcha is warmer there than here! @$?&! 33* last night! I am ready for winter to end now, OK? God, can you hear me?!
> 
> Ok, can't wait to see the monitor strip. Must be unique if it is circulating the hospital. Those hospital peoples don't usually get excited by that kinda stuff unless it is really good. :-D



92 degrees in the shade at 0900


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## 8jimi8

still trying to acquire the strip.


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## wyoskibum

*Junctional tachycardia?*



8jimi8 said:


> Wish i saved a strip...
> 
> Anyway, our most experienced monitor tech was calling me and calling me freaking out about the p waves this guy had, were firing on his t waves... And i was like.. what do you want to know? Its PACs he's been doing this all night.
> 
> But then she keeps on freaking out like I needed to give her more information.  For the life of me i couldn't figure what she was getting at.
> 
> It looked like a slow SVT around 85 b/min, although there were T waves (not often seen in svt)
> 
> so i've been searching around, anyone know of any significance of the P waves firing on the Ts?



Is there a P wave before the QRS and then an additional P wave on the T wave?  If so, is there a QRS after the P on T wave?  Or was it a P wave after the QRS?  It is not unusual to have a p wave after the QRS in a junctional rhythm and may look like it's part of the T wave.  A junctional rhythm would be regular and at rate around 40 bpm. 

You could also march out the P waves to determine if they are firing at regular interval and compare with the QRS (R to R) interval.  If both are regular, but not coordinating with each other, then it could be some type of block.

Definitely need to see the the strip to be sure.


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## dmiracco

Yes it could be a junctional strip with the p wave falling after the qrs or perhaps atrial enlargement with prolonged q-t interval. Hard to guess without the strip.


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## ExpatMedic0

It could also be the Tele tech was thinking of R on T and mixed it up with P on T. Each Tele tech comes from a different background with different training because there is no cardiac monitor technician training course that I am aware of.


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## 8jimi8

schulz said:


> It could also be the Tele tech was thinking of R on T and mixed it up with P on T. Each Tele tech comes from a different background with different training because there is no cardiac monitor technician training course that I am aware of.





No, she knows about R on T.  I know she wasn't worried about that because I made sure that wasn't what she was talking about, when she called me.  The CRT nurse, I believe, who kept a copy should be working tomorrow.  Hopefully she really did keep a copy.


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## DV_EMT

I'm currently a telemetry tech at our hospital. perhaps i might be able to help.

It couldn't really be SVT since the textbook definition is a rate usually around 140-160 or higher.

PAC could be likely since you seem to believe that the P was on to of the T.

Was the patient on any medications that could have caused QT prolongation or caused the patient to have a prolonged PR. If so, it could have been medication interference causing PAC. 

If it was a faster rate, i would guess PAT or SVT but I'd have to look at the strip.

Also, was there a chance of any artifact? was there a procedure going on?

Non-conductive PAC's is also an option, was there a significant pause? sometimes that can be misconstrued as a P on T.

Was the patient paced?


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## 8jimi8

I'm sorry for such the drawn out teaser.  No strip can be produced.   I spoke with the pts cardiologist.  There is no significance, it was merely "coincidence" that the p's landed on the t's.  He confirmed my earliest suspicion, they were just pac's


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