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American Journal of Critical Care. 2002;11: 577-578
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ECG PUZZLER
A regular feature of the American Journal of Critical Care, the ECG Puzzler addresses ECG interpretation for clinical practice. We welcome letters to the Editors regarding this feature.

Bradycardic ECG Monitoring Alarms

By Michele M. Pelter, RN, PhD and Mary G. Adams, RN, PhD. From the Department of Physiological Nursing, University of California, San Francisco, Calif (MMP) and the School of Nursing, the State University of New York at Buffalo (MGA).

Scenario: This is an alarm printout (lead V1 and V6) indicating bradycardia for a heart rate of 39 beats per minute in an 80-year-old Chinese man monitored in the transitional care unit. The patient has a history of coronary artery disease and congestive heart failure. Upon assessment, the patient is lying comfortably in bed and his vital signs are stable. Blood pressure is 126/66, pulse is irregular, and respiratory rate is 20 breaths per minute.



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Interpretation: Ventricular bigeminy at 80 beats per minute.

Rationale

In this example, each normal beat is followed by a premature ventricular contraction (PVC) occurring in a bigeminal (every other beat) rhythm. These beats are ventricular because the QRS is wide, bizarre (>0.12 seconds), and positive in V1. The ST-segment depression seen with the PVCs is due to abnormal repolarization and not myocardial ischemia. The morphology of the PVC indicates that the origin is from the left ventricle, because the impulse travels upward and rightward, resulting in a positive QRS. Premature ventricular beats originating in the left ventricle are more common in patients with heart disease.

Importantly, the bedside monitor alarm sounded for bradycardia (39 beats per minute) because only every other beat is detected. However, when calculating heart rate, every QRS complex is counted. To calculate heart rate in this example, count the number of QRS complexes in a 6-second sample using the 3-second tick marks ({blacksquare}) and multiply by 10. In this example, there are 8 QRS complexes between the two 3-second intervals (8 x 10), thus the heart rate is 80 beats per minute.

Nursing Actions

Two initial actions should be taken in this example: (1) assess the patient and (2) interpret the alarm. Given that the patient is stable, that the heart rate is actually 80 beats per minute, and that this is not a new rhythm, no action is indicated.





This Article
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Right arrow Articles by Adams, M. G.

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