I've been faced with this and wasn't sure of the best approach. If you have a pt in the ED with a HR on the monitor in the 70's or 80's, but is spiking multiple PVC's or bigeminy, do you immediately do a manual check of the pt's radial pulse to assess the actual perfusing HR( Subtract the PVC's)? If the patient is then actually bradycardic without the PVCs and is symptomatic do you treat this. Or if you have some old person who isn't symptomatic with normal HR with PVCs but slow brady without them do you work them up for bradycardia? I was told not to count PVCs in the HR.
normal HR on monitor, but sx bradycardia
- Thread starter prolene60
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Gotta assume that physiologically you need to treat the actually physiologic condition measured by pulses per minute, not the monitors measurement if waveforms. But I'm sure treating PVCs with prokinetic and rate increasing drugs is going to lead to some interesting outcomes once you get the actual pulse increased.
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I've had this happen before, pt with trigeminy with a rate near 90 but actual pulse more like 30 and was hypotensive. We gave dobutamine to kick her heart a little more and then got a real pulse of 80 and her BPB normalized.
D
deleted109597
Depends on if the PVC is perfusing or not. Only count the beats with pulses, so first start with a pulse check. Thus, treat the patient, not the number.
PVCs aren't always bad, but poor perfusion is.
PVCs aren't always bad, but poor perfusion is.
Same as above. I had a bigeminy with a heart rate 70 and pulse rate of 35 who was feeling symptomatic. By the same token I have also had people with a heart rate of 50 to 60 in bigeminy that were doing fine with a pulse rate of 50 to 60
Someone in our dept had a similar case once. CC was dizziness. BP was nl. Pt's rhythm was sinus in origin with very frequent PVCs with a rate on the monitor of 70. Palpated HR was 30. Cardiologist recommended a betablocker with the reason being that suppression of the non palpable/nonperfusing PVCs would allow the sinus node to provide a more effective rhythm with QRS complexes that actually perfuse the body. Dont ask what happened...I havent been able to followup.
Does anyone look at the pulse ox HR to determine the patients perfusing pulse? I use this as a cheat when the patients monitor is beeping like crazy showing a rate of 180 but its just reading T waves (the true rate is 90) or to tell if a transvenous pacer is causing mechanical capture
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deleted171991
I would set the monitor to count the beats by the pulse oximeter wave, instead of the ECG wave.
There is a reason doctors have been checking the pulse for centuries, instead of counting heart sounds. That's because an ineffective contraction, which does not generate a pulse wave, does not matter hemodynamically.
Disclaimer: I am an anesthesiologist.
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Understand the theory, but would sure make me nervous pushing AV nodal in symptomatic bradycardic pt.
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deleted171991
Makes sense to me. If in doubt, push some esmolol; it will wear off fast.
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Yeah call me old fashioned (or a bad intern) but I'd feel more inclined to watch cards push BBs once pt is in the unit...after I've pushed atropine/paced them downstairs.
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deleted171991
I prefer to try 0.2 mg glycopyrrolate first, too, to bring up the SR, and see if the PVCs decrease.
Disclaimer: I am an anesthesiologist.
Disclaimer: I am an anesthesiologist.
