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Dynamics of Critical Care 2008 CACCN, Montreal, Canada Pulling it all Together Case Studies in ECG Monitoring, Part 1 Barbara J. Drew, PhD, RN, FAAN Professor of Medicine & Nursing University of California, San Francisco UCSF UCSF When attaching a cardiac monitor, assess patient's need for 3 potential goals of monitoring Arrhythmia Ischemia? (ST-segment monitoring) QT interval? AHA Practice Standards for ECG Monitoring in Hospital Settings Circulation 2004 Practice Standards for ECG Monitoring Recommendations: 1. Monitor at least 2 leads 2. Leads V1 & II Arrhythmia Monitoring V1 1. Select the best ECG leads for arrhythmia diagnosis II UCSF Advantages of Lead II Advantage of Lead V1 Provides a tall R wave in most people (accurate heart rate detection, less noisy signal) Diagnosis of rhythms with a wide QRS complex (e.g., BBB) Shows clear-cut saw-tooth atrial waves in atrial flutter Distinguish VT from SVT with aberrant conduction UCSF Advantages of V1 for arrhythmia monitoring V1 is the best Lead to diagnose Right Bundle Branch Block (RBBB) Occlusion of the LAD with acute anterior MI may cause bundle branch & fascicular block Left Main Artery A-V Node Bundle of His Right Coronary Artery (RCA) Left Anterior Descending (LAD) LBB Left Posterior Fascicle R′ Posterior Descending r Left Anterior Fascicle RBB s UCSF UCSF Advantages of V1 for arrhythmia monitoring Advantages of V1 for arrhythmia monitoring Patient in CCU with acute anterior MI Lead V1 10:00 am Patient A has VT (dx from EP study) V1 Lead V1 1:00 pm II Lead V1 4:00 pm (Temporary transvenous pacer was being inserted) If lead II had been monitored instead of V1, there would have been no warning prior to CHB and ventricular standstill Taller Left Peak Pattern = VT Drew & Scheinman, PACE 1995;18:2194 UCSF Advantages of V1 for arrhythmia monitoring Patient B has SVT with aberrant conduction (dx from EP study) Advantages of V1 for arrhythmia monitoring Patient C has VT (dx from EP study) notch on S downstroke V1 V1 rsR′ or rR′ pattern = SVT = VT II II QRS onset to S nadir interval >.06 sec Drew & Scheinman, PACE 1995;18:2194 UCSF UCSF Drew & Scheinman, PACE 1995;18:2194 Advantages of V1 for arrhythmia monitoring LA V1 requires 5 electrodes Patient D has SVT with aberrant conduction (dx from EP study) V1 RA C II ALL of these criteria in both V1 & V2 plus no Q in V6= SVT no R ≥ .04 sec no notch on S downstroke QRS onset to S nadir < .06 sec RL Drew & Scheinman, PACE 1995;18:2194 UCSF LL UCSF Practice Standards for ECG Monitoring V1 Arrhythmia Monitoring II V1 2. Place electrodes in their correct anatomic site II UCSF From Anita Christiansen, RN, MS, CCRN, Good Samaritan Hospital, San Jose How accurate is Lead placement? Random survey of RN’s in USA What were the errors? 300 250 200 # RNs 150 electrodes 77% 100 50 23% 0 Correct Incorrect UCSF UCSF Practice Standards for ECG Monitoring Recording an AEG from epicardial pacemaker wires Drew BJ, et al. Heart & Lung 1991;20:597-609. Arrhythmia Monitoring 3. Print out an AEG whenever a post-op. cardiac surgery patient develops a tachycardia of unknown mechanism UCSF Ventricular Wires Atrial Wires Kern LS, et al. AACN Adv Crit Care 2007;18:294-304 Wear rubber gloves to protect patient from microshocks Wrap atrial wire in chest lead-wire Use chest (V) lead-wire (brown) Either atrial wire may be used Printing an AEG Sample AEG 1. Set up printer to print simultaneous limb & “V” lead AEG has larger P waves than monitor leads 2. Print a long strip of the rhythm. Re-label the “V” lead as “AEG” From Marion McRae, Acute Care Nurse Practitioner, Cardiac Surgery, Toronto General Hospital UCSF What is the rhythm? Lead II UCSF What is the rhythm? 70 y/o post-cardiac surgery patient P Heart rate 146 bpm (220 - 70 = 150) Atrial fibrillation AEG Sinus tachycardia UCSF From Marion McRae, Acute Care Nurse Practitioner, Cardiac Surgery, Toronto General Hospital Practice Standards for ECG Monitoring Top priority for ST segment monitoring Ischemia (ST- segment) Monitoring 1. Present to the ED with chest pain 2. Admitted to the hospital with acute coronary syndrome (unstable angina or acute MI) 3. Post PCI with complications in the cath lab (vessel dissection) or a suboptimal angiographic result 1. Identify patients who need ST-segment monitoring UCSF AHA Practice Standards for ECG Monitoring in Hospital Settings Circulation 2004 ST alarm is an earlier sign of abrupt reocclusion following PCI than chest pain Post PTCA of RCA & dig Rx 10:00 am ST monitor alarm 10:30 am Best ECG leads to detect occlusion of the 3 main coronary arteries Chest pain 10:45 am I LCX V3 II III RCA III, aVF, II aVR aVL LAD V2, V3 aVF UCSF Drew BJ et al. J Electrocardiol 1998;30:157-165 Recommended leads for ST-segment monitoring: II or III + V3 Aldrich HR et al. Am J Cardiol 1987;59:20 Bush HS et al Am Heart J 1991;121:1591 Drew BJ & Tisdale LA. Am J Crit Care 1993;2:280 UCSF IMMEDIATE AIM Study Initial ECG in 40 y/o male presenting to the ED with increasing chest pain episodes; Troponins negative 5:00 pm LA RA LA LL C V3 C RL C RA RL LL IMMEDIATE AIM Study 6 days following hospital discharge, patient was brought to ED after witnessed collapse on golf course UCSF UCSF IMMEDIATE AIM Study Rapidly developed profound shock, could not be resuscitated, and died UCSF Practice Standards for ECG Monitoring R QT Interval Monitoring Certain drugs prolong QT interval & put patient at risk for developing TdP T P 1. Measure QT intervals to prevent cardiac arrest due to druginduced Torsades de Pointes UCSF S How long it takes the ventricles to repolarize Generic Name QT prolonging drugs Torsades de Pointes www.torsades.org Risk Factors: Rapid administration (IV route) Renal / hepatic dysfunction Hypokalemia, hypomagnesemia QT=0.64 sec (640 ms) Bradyarrhythmias with long pauses (sinus arrest, CHB) Female gender (70% of druginduced TdP cases are women) Advanced age Upper limits of normal = 460 ms, males 470 ms, females Heart disease (LVH, HF) UCSF Things to know about QT measurement QT interval gets shorter with increasing HR and longer with decreasing HR QT must be corrected for heart rate (QTC) QT interval Q Poly-pharmacy Brand Name(s) Clinical Use Amiodarone Cordarone, Pacerone Anti-arrhythmic Arsenic trioxide Trisenox Cancer/Leukemia Bepridil Vascor Anti-anginal Chlorpromazine Thorazine Anti-psychotic Cisapride Propulsid GI stimulant Clarithromycin Biaxin Antibiotic Disopyramide Norpace Anti-arrhythmic Dofetilide Tikosyn Anti-arrhythmic Domperidone Motilium Anti-emetic Droperidol Inapsine Sedative; Anti-emetic Erythromycin E.E.S., Erythrocin Antibiotic Halofantrine Halfan Anti-malarial Haloperidol Haldol Anti-psychotic Ibutilide Corvert Anti-arrhythmic Levomethadyl Orlaam Opiate agonist Mesoridazine Serentil Anti-psychotic Methadone Dolophine, Methadose Opiate agonist Pentamidine NebuPent, Pentam Anti-infective, Pneumocystitis Pimozide Orap Anti-psychotic Procainamide Pronestyl, Procan Anti-arrhythmic Quinidine Quinaglute, Cardioquin Anti-arrhythmic Sotalol Betapace Anti-arrhythmic Sparfloxacin Zagam Antibiotic Thioridazine Mellaril Anti-psychotic Case Example 78 y/o woman started on IV erythromycin Baseline QT interval prior to start of drug = 0.44 sec (440 ms) HR = 60, QTC = 440 ms QTC tells you what the QT interval would be if the HR were 60 bpm QTC >500 ms is dangerous; consider stopping the drug to prevent TdP UCSF On the next shift, her QT interval on the drug = 440 ms HR = 80, QTC > 500 ms What else do we need to know? Incidence of drug-induced events TdP QTc > 500 ms Distinguishing TdP from ventricular fibrillation Rare Uncommon 64 y/o male on no medications presents to the emergency dept. with symptoms of acute MI 60 bpm QT Prolongation Common Heist & Ruskin, Heart Rhythm 2005;S1-S8. QT=440 ms UCSF Methods to monitor QTC in hospital units UCSF Sequence of ECG events in TdP 1. Standard "diagnostic" 12-lead ECG Typically, only one/day ↑ QTC >500 ms after start of drug 2. Manually with calipers; apply correction formula Polymorphic PVC’s & couplets Time-consuming; inter-rater differences T wave alternans may/may not occur 3. E-calipers from the Central Monitoring Station Still time-consuming; inter-rater differences Non-sustained TdP after pause 4. Continuous QT monitoring Measures QTc every 5 mins; no inter-rater differences; alarm alerts for ↑QTc from baseline >60 ms or QTc >500 ms Sustained TdP and cardiac arrest UCSF UCSF One hour earlier… Elderly woman in the ICU being treated with IV erythromycin PVC’s & couplets Lead V1 Lead V1 Lead II Lead II T wave alternans UCSF Drug should have been stopped here to prevent TdP !!!