Answers

I asked for suggestions on a strange EKG I snagged at work here in this post.

Many good suggestions, and a couple did guess correctly:   it is artifact.  I know, all that build-up for nothing, so disappointing, right?

The night I grabbed this though the patient had been admitted earlier on shift and had been in normal sinus rhythm since arrival.  This popped up and the tele tech asked someone to see what was going on as it was a retty major shift from the baseline.  It wasn’t obviously artifact, but very different from previous.  So we go down the hall and into the room and are greeted with the patient laying prone on her bed, tele leads and box squished under a rather substantial girth.  We convinced her to roll over and her tele returned to normal.

Just a little example as to how even artifact can look like something (or nothing at all) and why we as nurses should always remember that when something looks out of normal, we need to check it out.

I grabbed a cool strip this week but am heading out of town and won’t be able to post it until next week, but trust me, it’s a keeper.  Have a great weekend!

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2nd Degree AV Block, Type I

Otherwise known as Wenckebach, or perhaps my favorite of the AV Blocks.  It has a certain je-nes-sais-quoi to it.  It is dynamic, but rather non-threatening.

wenckebach1

The classic definition of 2nd Degree AV Block, Type I, is an increasing PR interval until a QRS complex is dropped.  “Longer, longer, drop, you’ve got yourself a Wenckebach” is a nice little mnemonic to remember when determining the rhythm.  Starting from the 4th beat in on the strip, you can see the PR interval goes from .24s, .26s, then .36s and a complex is dropped in the next round.  But you ask, where is the P wave for the dropped complex?  It’s buried in the T-wave from beat #6.  One other identifying feature of Wenckebach is that the P-P interval remains constant, in this case .64s, and the R-R interval lengthens as well.

Normally, this is a problem with the AV node, although there are some occasions where it occurs below the node, in the His-Perkinje fibers.  Occasionally you will get wide and bizarre QRS complexes with both above and below the node eitilogies, but more commonly narrow complex QRSs will be the norm.

Causes can include drug induced, from beta and calcium channel blockers, digoxin and amiodarone, also in cases of acute myocardial infarction (most commonly inferior wall).  Unlike Type II block which can evolve into 3rd degree block, Type I does not evolve into anything worse on its own.  Patients are rarely symptomatic just from the rhythm, and symptoms are usually a result of the precipitating factors. Unlike 3rd degree block, there is not much for us nurses to do except to monitor the patient.  As these folks are usually asymptomatic, it’s all we can do.  Past that, if symptoms are present, we can treat the symptoms.

And just because we’re talking Wenckebach, I have to include the classic YouTube gem:

Angiography: Live and In-Person

BBC NEWS | Health | Watch an emergency heart procedure

This is far too cool.  Patient is a 36 year old male, with a blockage of his RCA (according to the cardiologist). Risk factors?  Smoking. I lived in England for 3 months and am sure that smoking was not the only risk factor…but.

I wish they had displayed a copy of the EKG, but I would venture to guess there was some ST-segment elevation for them to rush him back to the cath lab so quickly.  They show a fluoro shot of the dye being injected then stopping, which gives a great visual representation of what is going on.  You can see how it is pretty much totally blocked.  Then they also show a fluoro shot prior to stenting where you can see the narrowed lumen of the artery. Unfortunately, these shots are pretty much fleeting in nature so to get the best view you would have to pause the video, which I highly recommend.

It’s fun, especially when the patient has a bit of a reperfusion arrhythmia!

via Dr. Wes

Just Bizarre

Really?

Really?

Yessiree, I’m gonna’ get me some chicky chicky boom boom for dinner tonight.

As I had been out imbibing adult beverags with work colleagues earlier in the night, this sounded, well, near-delightful.  Luckily for me, cooler heads prevailed and there was no chicky chicly boom boom bought.  More than anything I just love the name.  AlthoughI wonder if that is a code name for certain acts…

Junkfood Science: National Patient Registry

Junkfood Science: National Patient Registry

The article explores the various legal and ethical pitfalls associated with EMRs…and it’s incredibly fascinating.  And it is a little scary, to realize that the creation of a national database would have far reaching effects onto the delivery of care and the provisions of privacy (or lack thereof).  One thing that struck me was the discussion of HIPPA and privacy, citing Supreme Court dialogs about the privacy of a persons’ medical record.

Being involved in an EMR transition project it brought up things I didn’t really consider and it is great food for thought.  It’s heavy reading but well worth it.

Targeted Advertising

I was watching the evening news tonight through heavily lidded eyes, but something very evident occurred to me:  people my age don’t watch the news.

How did I figure this out?  Commercials.  During 1 break that I was a little more cognizant for I saw a commercial for Plavix, Miralax and CVS pharmacies.  Not many folks in their 30’s need to take anti-platelet medications.  Sure some need to keep the GI tract moving and we all need a place to pick them up for sure.  But the general bent to these few commercials I was coherent for were obviously targeted to a older demographic.

Just a random observation.  I was really watching the evening news to compare broadcasts, NBC versus BBC America.  The depth and scope of coverage between the 2 was very different, vastly different.  Once again, targeted.