EKG Question From a Paramedic Student

[MrJones]

To me that's backwards. I'll do an automated one and a manual to confirm the machine. I don't trust them.

My practice is to always get the first pressure and pulse manually. For one, I don't always tote the monitor into the house, but I always have my 'scope, cuff and watch. As well, feeling and listening for myself tells me things about the patient that the monitor/auto-cuff doesn't. And, if you think about it, it also forces you to slow down and pay attention to the patient, something that can be important in the first few moments of a contact.

 

[NPO]

My practice is to always get the first pressure and pulse manually. For one, I don't always tote the monitor into the house, but I always have my 'scope, cuff and watch. As well, feeling and listening for myself tells me things about the patient that the monitor/auto-cuff doesn't. And, if you think about it, it also forces you to slow down and pay attention to the patient, something that can be important in the first few moments of a contact.

Agree on all points. Except on not taking the monitor in. Its policy for us. I'm quick to dismiss a NIBP and pull out a manual if something smells fishy, or just go straight for manual if I have a feeling it might be high, low, or hard for the machine to get from any reason.

 

[MedicJon88]

hey, so i'm trying to break the strips down to analyse it like I would at my work. using the 12 lead.
Slightly Irregular in Rate
PR- un-measureable
QRS looks like its at .12
Rate is in the 50s
looks like the P waves are not correlated with the QRS

my interpretation 3rd degree heart block with Junctional rhythm

 

[tpchristifulli]

Figure out why her sp02 was 88% .... Is she normally on 02? ABC's.

 

[Jason]

I'm leaning towards 3rd Degree HB. And if the Pt is stable, then supportive measures, O2, IV, Monitor. I would not use atropine in this rhythm. If the Pt became symptomatic, I would pace. Atropine is not ideal for 3rd Degree, because all you really get is a faster 3rd Degree and potentially make it worse.

 

[Handsome Robb]

my interpretation 3rd degree heart block with Junctional rhythm

Never heard a CHB analyzed that way. With that said the morphology and duration indicates a junctional focus for the QRS rather than the normal "wide and ugly" ventricular foci.

I agree that atropine isn't a diagnostic tool as it could worsen the patients condition.

 

[Akulahawk]

I went back through the strips and that's a good way to describe what's going on. What I saw was: 3rd Degree block, junctional rhythm, and probably LBBB...

I wouldn't give atropine as it's not likely to improve anything... and if the patient's condition worsens, fire up the pacer and provide a nice ride.

 

[Brandon O]

Never heard a CHB analyzed that way.

Which part?

 

[Christopher]

Never heard a CHB analyzed that way.

Perhaps it would be better stated as "sinus rhythm, complete heart block, and a junctional escape with LBBB."

Although, I disagree that CHB is present due to evidence of variable R-R intervals on the 3-Lead. This indicates some conduction is possible.

 

[Mantis Toboggan]

I'm leaning towards 3rd Degree HB. And if the Pt is stable, then supportive measures, O2, IV, Monitor. I would not use atropine in this rhythm. If the Pt became symptomatic, I would pace. Atropine is not ideal for 3rd Degree, because all you really get is a faster 3rd Degree and potentially make it worse.

Atropine will not affect the rate in a 3rd degree block, for better or worse. In the case of a CHB, the automaticity foci in the ventricles have assumed the role as pacemaker due to a conduction failure of the AV node. The SA and AV nodes are the only parts of the heart with parasympathetic innervation—via the vagus nerve. Atropine 'speeds up' the heart by inhibiting the action of acetylcholine, decreasing parasympathetic tone. The ventricular rate of a 3rd degree block can be quickened by sympathomimetics like epi (not recommended) or through TDP. The slow ventricular response is linked to the intrinsic firing rate of the automaticity foci (20-40) and not by parasympathetic tone (which is absent—distal the AV node).

 

[Christopher]

Atropine will not affect the rate in a 3rd degree block, for better or worse.

Not quite true. It will not affect a ventricular escape rhythm. If the AVB is vagally mediated, then atropine may improve conduction (common in IWMI). If the escape is junctional, then atropine may improve the rate.

In the case of a CHB, the automaticity foci in the ventricles have assumed the role as pacemaker due to a conduction failure of the AV node. The SA and AV nodes are the only parts of the heart with parasympathetic innervation—via the vagus nerve. Atropine 'speeds up' the heart by inhibiting the action of acetylcholine, decreasing parasympathetic tone. The ventricular rate of a 3rd degree block can be quickened by sympathomimetics like epi (not recommended) or through TDP. The slow ventricular response is linked to the intrinsic firing rate of the automaticity foci (20-40) and not by parasympathetic tone (which is absent—distal the AV node).

This is all "true", assuming a distal block in the AVN and a ventricular escape.