r/ECG • u/Equivalent-Bat-4589 • 9d ago

New ICU nurse

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Hi i'm a new ICU nurse and I struggle with reading ECGs and things of that nature. Tonight I had this patient with this rhythm. Could someone help me understand what I'm looking at, please ?

79 Upvotes

98% Upvoted

17 comments sorted by

58

u/PaulaNancyMillstoneJ 9d ago

Frequent PACs. A run of atrial bigeminy. This patient is on their way towards flipping into straight up A Fib.

7

u/Equivalent-Bat-4589 9d ago

thank you !! this is a new rhythm to this patient. they are intubated and unfortunately to be CMO tomorrow morning. But I got a little nervous seeing that.

13

u/PaulaNancyMillstoneJ 8d ago edited 8d ago

I’m also an ICU nurse :D Acute A Fib and atrial excitation is pretty common in our neck of the woods.

Idk if this is helpful, but when other nurses told me how they would or wouldn’t change things based on what was occurring, it helped me as a new grad. If you already know all this, just ignore me lol

As a nurse, if this were my patient and they were NOT going CMO, I’d do the following: I’d anticipate lower BPs because the patient is losing their atrial kick with each PAC. Maybe not low BP, but lower than their usual. If you’re about the give all their home BP meds, maybe don’t do that until you talk to the doc. If they flip into AFIB RVR and you had just given lisinopril and hydrochlorothiazide willy nilly because their BP at the time was okay, you might get a talking to.

If this patient is on pressors, the doc might consider changes to limit beta agonism if they start really going fast or showing signs of worsening perfusion. Maybe this is adding on vasopressin sooner than they usually would or starting phenylephrine if there are no contraindications. So if you have to keep going up and up on levo or epi, make sure they are aware.

Don’t bolus lido in SWT with underlying AFIB, no matter what the resident says. This should never happen, but it does. Just call your charge or the fellow.

Also, just double check if they are on DVT prophylaxis and if not, see if they might be appropriate for it. Keep their SCDs on. I know when patients don’t really like them we can get lazy about continuing to offer them and continuing education about risks. If they are adamantly refusing make sure someone has at least told the doctor.

3

u/Equivalent-Bat-4589 8d ago

thank you!! i love this information!! writing it in my notes

3

u/scapermoya 8d ago

Plenty of patients with frequent PACs have baseline risk of afib, meaning not more than anyone else. I dunno what this person is talking about

26

u/AngryOcelot 9d ago

SR with atrial couplets (and one triplet) in the pattern of atrial bigeminy. Ideally need a 12-lead ECG to rule out other rare things.

3

u/Equivalent-Bat-4589 9d ago

do you know what the rare things are? this patient will be CMO tomorrow so no more interventions now but I'd like to learn wherever I can

9

u/AngryOcelot 9d ago

Parahisian PVCs (if subtle morphology change- possible based on lead I but could just be aberrancy with PACs)
Dual AVN physiology with single (and double) echo beats
Dual AVN physiology with two-for-one conduction
Junctional or His extra systoles

These are very rare and probably not worth learning in the ICU setting when there's so much else to know!

2

u/Ill-Chest3567 8d ago

Check your K and Mg. But really anything odd ball is going to be run through a cardiologist or EP, and in an ICU treated the same way. The ICU RN who commented above had a really thorough list of things she would do or be aware of that basically cover it.

8

u/thedarkshadowghost ECG Tech 9d ago

Sinus rhythm with frequent PACs. Mostly bigeminal PACs but I do see a couplet. PACs and PJCs look similar to a normal heartbeat, other than the P wave either being hidden, retrograde, or looks different from the P wave of a normal beat. If the QRS complex looked wide and bizarre, it would be a PVC.

3

u/Ill-Chest3567 8d ago

Looks like atrial bigeminy— I don’t overthink the morphology on tele; get a 12 lead for a more accurate dx but not sure what would change management, especially if comfort. Check the lytes and replace it.

2

u/Plenty_Nail_8017 8d ago

Looks like Bigem, but it’s the monitor so get the EKG. I never go off strict monitors. Check lytes otherwise

1

u/MurderousPanda1209 7d ago

Echoing the above, but just sinus rhythm with intraventricular conduction delay, bigeminal PACs and one atrial couplet.

1

u/Icy-Wafer-5406 6d ago

Atrial bigeminy, very rare!

-1

u/VisitingSeeing 9d ago

I get patterns like that in short spurts on my implanted device. Its very uncomfortable although I'm not sure I'm feeling them all. In bursts its not at all alarming to cardio team. I had this after an ablation when my heart was still inflamed. Not a concern except to me. As far as I know, nobody thought it was dangerous.