# Palp a 2nd Degree Block?



## NPO (May 10, 2013)

I was doing a BLS transfer. Discharge to SNF. Patient was asymptomatic, and VS were all WNL when we left. I dont recall what the guys C/C was, but it was not cardiac in nature, and not severe. Probably could have taken a taxi. 

In my county it is not within my scope to use a cardiac monitor, and by extension, automated NIBP is not available. This means manual BP for every transport, every 15 mins, minimum 2 sets. I usually knock one out at the sending facility with their BP machine. 

So in the hospital he looked good on the BP machine. But while transporting, I noticed something weird. He did not come from a telly floor, so they wouldnt have noticed it either, just using the BP machine. His heart would 'pause' every third beat. Now obviously I cant detect the presence of a P wave with my finger on his radial, but there was a VERY distinct pause every 3rd beat.

I reviewed the PT's packet, and no reference of any dysrhythmias anywhere. Not so much as a note. 

Do you think he was in a 2nd degree I or II block? Or is this something else that I've not heard of. His rate was regularly irregular. Beats 1, 2, and 3 were marching out correctly, but that 4th beat was absent.

Thoughts? Would you have turned around?


----------



## Arovetli (May 10, 2013)

maybe a 2nd degree type 1. even if so, they are fairly benign. no turn around.


----------



## JPINFV (May 10, 2013)

Arovetli said:


> maybe a 2nd degree type 1. even if so, they are fairly benign. no turn around.




Without a rhythm strip, how are you differentiating between 2nd degree type 1, 2nd degree type 2, and something strange like quadgeminy (PVC q4 beats)?


----------



## Arovetli (May 10, 2013)

JPINFV said:


> Without a rhythm strip, how are you differentiating between 2nd degree type 1, 2nd degree type 2, and something strange like quadgeminy (PVC q4 beats)?



without a rythym strip i could pull a million things out of the atmosphere. 
the kid asked about 2degree blocks, and with his description, a type 2 is less likely than a type 1. im not differentiating anything, hence the word 'maybe'. im also not turning the ambulance around without anything other than feeling a dropped beat q4


----------



## NPO (May 10, 2013)

Arovetli said:


> without a rythym strip i could pull a million things out of the atmosphere.
> the kid asked about 2degree blocks. im not differentiating anything, hence the word 'maybe'. im also not turning the ambulance around without anything other than feeling a dropped beat q4



So why did you specify a type I? Theres really no way to tell without a strip.

The point wasnt to decide between Type I and II but if it was a 2nd Degree or something else that I wasnt aware of.

A q4 PVC was mentioned, but wouldnt a PCV be palpable? I have, now that I think about it, never tired.


----------



## JPINFV (May 10, 2013)

Arovetli said:


> without a rythym strip i could pull a million things out of the atmosphere.
> the kid asked about 2degree blocks. im not differentiating anything, hence the word 'maybe'. im also not turning the ambulance around without anything other than feeling a dropped beat q4




For a presumably short discharge transport? Sure. However, if it's new it's something that definitely needs to be worked up. It doesn't have to be an acute care hospital workup, but it's definitely something that the patient's primary physician needs to be made aware of if it's new.


----------



## JPINFV (May 10, 2013)

NPO said:


> The point wasnt to decide between Type I and II but if it was a 2nd Degree or something else that I wasnt aware of.



The problem is that there's a big difference between type 1 and type 2. Type 1 is, as mentioned, pretty benign. Type 2, on the other hand, is bad juju. 



> A q4 PVC was mentioned, but wouldnt a PCV be palpable? I have, now that I think about it, never tired.


Not always. There will also be a compensatory pause following the PVC, so maybe you're feeling beat, beat, PVC, compensatory pause. Repeat (thus making it a trigeminy rhythm).


----------



## NPO (May 10, 2013)

JPINFV said:


> ...but it's definitely something that the patient's primary physician needs to be made aware of if it's new.



Which for the sake of discussion is what happened. Transport was continued and his PCP was notified. I dont know what came of it after that.


----------



## Arovetli (May 10, 2013)

NPO said:


> So why did you specify a type I? Theres really no way to tell without a strip.
> 
> *because if you are asking of second degree blocks, given your description a type one would be more likely.*
> 
> ...



response above.


----------



## NPO (May 10, 2013)

JPINFV said:


> The problem is that there's a big difference between type 1 and type 2. Type 1 is, as mentioned, pretty benign. Type 2, on the other hand, is bad juju.



So I was going to say, 'But there is no way to tell without a strip."

But the pt was asymptomatic, which would lead one to lean towards Type I, which I assume is where Arovetli pulled that from.


----------



## Arovetli (May 10, 2013)

it is unlikely that a type 2 would be that consistent with its beat dropping.
if you are asking about second degree blocks being regularly irregular, likely culprit is wenckenbach.

but, i feel quite foolish discussing heart rhythms based on pulse palpation.


----------



## NPO (May 10, 2013)

Its just discussion for the sake of discussion. Just curious what would cause a q4 beat drop like that. I agree that a 2nd degree woudlnt normally run like clock work like that. But I've seen weirder things.


----------



## Carlos Danger (May 10, 2013)

JPINFV said:


> Without a rhythm strip, how are you differentiating between 2nd degree type 1, 2nd degree type 2, and something strange like *quadgeminy* (PVC q4 beats)?



Quadrigeminy?

Or is this something different?


----------



## Brandon O (May 10, 2013)

Arovetli said:


> but, i feel quite foolish discussing heart rhythms based on pulse palpation.



Silly for sure, but us BLS guys have to take 'em where we can get 'em.

I am a pulse fetishist and have palpated many a perplexing regularly irregular rhythm. Most often, it's either an intermittent dropped beat (perhaps a type II or regular PVCs), an intermittent additional beat over a regular underlying rhythm (presumably ectopy), or paired beats, sometimes palpably strong-weak in pattern (presumably bigeminy, although in rare cases maybe alternans). But you'll also get fooled sometimes by A-fib which is just awfully regular feeling most of the time.

Of course, there's also my reported "rapid A-fib patient" who turned out to be in a stable V-tach. What are ya gonna do. (Get that iPhone ECG app? I didn't say that.) Cardiac auscultation can help a little, mainly by identifying non-perfusing beats (for instance, is the pause you're feeling preceeded by a pulseless PVC?)

Not to be obnoxious, but most of the time it's a matter of "treat the patient, not the pulse."


----------



## Handsome Robb (May 10, 2013)

NPO said:


> A q4 PVC was mentioned, but wouldnt a PCV be palpable? I have, now that I think about it, never tired.



Ectopic beats can be perfusing or non-perfusing.


----------



## JPINFV (May 10, 2013)

Halothane said:


> Quadrigeminy?
> 
> Or is this something different?


Google has both spellings coming up with hits for PCV q4 beats.


----------



## Christopher (May 10, 2013)

NPO said:


> Do you think he was in a 2nd degree I or II block? Or is this something else that I've not heard of. His rate was regularly irregular. Beats 1, 2, and 3 were marching out correctly, but that 4th beat was absent.
> 
> Thoughts? Would you have turned around?



Food for thought, when Luciani and Wenckebach described decremental conduction through the AV node they did so without a surface ECG.

So the question remains, can you tell from a peripheral pulse the degree of AV block present?

Luciani used ventricular pressure tracings, and Wenckebach used a patient's radial pulse! Luciani did not appreciate the physiology behind his findings, while Wenckebach had access to pressure tracings from a frog's atria and ventricles. Using this he was able to characterize grouped beating due to decremental AV conduction (2AVB Type I), without an ECG!

Now, in the case of 2AVB Type I, if you were f'amazing enough to tell that the string of 3 beats prior to the dropped beats somehow had shortening of their timing in a regular pattern.....you could make the case!

Otherwise, you're left with deciding if you have 2AVB Type II from sinus bradycardia from non-conducted PAC's?

So don't let anybody tell you that you can't tell 2AVB Type I from just a radial pulse, because Dr. Wenckebach certainly didn't have an ECG.

Just keep in mind you likely cannot without some pretty detailed note taking and timing...

I like where your head is at!


----------



## chaz90 (May 10, 2013)

Dr. Wenckebach was a god. I'm always impressed at what people are able to discover, even with limits resources as compared to today's technology. Also, the man had style.


----------



## Handsome Robb (May 10, 2013)

I'm bringin' Wencke-bach!

http://m.youtube.com/watch?v=GVxJJ2DBPiQ


----------



## JPINFV (May 10, 2013)

Robb said:


> I'm bringin' Wencke-bach!
> 
> http://m.youtube.com/watch?v=GVxJJ2DBPiQ




What?


----------



## Handsome Robb (May 10, 2013)

JPINFV said:


> What?



Sorry diagnosis wenckebach.

You've never seen that video?


----------



## JPINFV (May 10, 2013)

Robb said:


> Robb said:
> 
> 
> > JPINFV said:
> ...




Actually, it's the second line of the music video... right after "Diagnosis Wenckebach."


----------



## Handsome Robb (May 10, 2013)

JPINFV said:


> Actually, it's the second line of the music video.



Yep. Couldn't remember what it said, went to watch it, got a call so just hit send on what I already had.

Won't happen again boss


----------



## Akulahawk (May 10, 2013)

Have you all forgotten about another very simple explanation... sinus pause? (Although the OP _did _ask about the Type 2 blocks...)


----------



## Arovetli (May 10, 2013)

this was my first thought...

inspiration coordinated with the 4th beat.

edit: i said that backwards.


----------



## Christopher (May 10, 2013)

Akulahawk said:


> Have you all forgotten about another very simple explanation... sinus pause? (Although the OP _did _ask about the Type 2 blocks...)



Sinus pause is a fairly uncommon cause of consistent dropped beats causing grouped beats. At that point you'd probably consider it a type 2 sinoatrial exit block.


----------



## Brandon O (May 10, 2013)

Akulahawk said:


> Have you all forgotten about another very simple explanation... sinus pause? (Although the OP _did _ask about the Type 2 blocks...)



Seems dubious for a consistently regular finding.


----------



## Akulahawk (May 10, 2013)

Maybe so, however, I've seen it happen and the person that had it wasn't aware of it until she actually took her pulse. She was also dropping the expected 4th beat, and it was timed quite well with her inspiratory effort. Since she was actually breathing about every 3-4 seconds...

Without actually seeing the strip... it could be a lot of things. Without a monitor, I also tend to actually listen while I take a pulse when I feel something is a bit "off" with the pulse.


----------



## Arovetli (May 10, 2013)

Akulahawk said:


> Maybe so, however, I've seen it happen and the person that had it wasn't aware of it until she actually took her pulse. She was also dropping the expected 4th beat, and it was timed quite well with her inspiratory effort. Since she was actually breathing about every 3-4 seconds...
> 
> Without actually seeing the strip... it could be a lot of things. Without a monitor, I also tend to actually listen while I take a pulse when I feel something is a bit "off" with the pulse.



i believe you and i are referring to a respiratory induced sinus arrythmia, and others are referring to a transient sinus arrest/pause. two different things, which may be leading to the confusion.

there is indication that heart rate can match the timing of the respiratory cycle, so its not too far of a stretch to say the pause OP experienced could be linked to the respirations but...idk, who knows


----------



## Akulahawk (May 10, 2013)

Arovetli said:


> i believe you and i are referring to a *respiratory induced sinus arrhythmia*, and others are referring to a transient sinus arrest/pause. two different things, which may be leading to the confusion.
> 
> there is indication that heart rate can match the timing of the respiratory cycle, so its not too far of a stretch to say the pause OP experienced could be linked to the respirations but...idk, who knows


That's precisely what I'm referring to.


----------



## Mariemt (May 14, 2013)

My husband's does that if he drinks too much caffeine. The doctor simply said to quit drinking so Much caffeine.


----------

