1. CEEG Monitoring in CCTC By: Dawna Van Boxmeer Staff Nurse, Critical Care Trauma Centre

2. What we will cover… Review expectations of the CCTC RN Getting started… Supplies Electrode Placement Monitor setup and printing Easy waveform analysis Questions

3. Expectations of CCTC RN Obtain a physicians order for CEEG monitoring Neuro ICU consult should also be obtained/requested by CCTC MD Proper application of electrodes

4. Supplies Needed Note: Electrodes, module, Nuprep and red dots will be kept in the Clean Supply Room, by Bay 3, on the far right hand wall (top shelf in the middle) Supply list: EEG module, EEG electrodes, alcohol wipes, 4x4 gauze, Nuprep, cotton swabs, 9 small red dots

5. Electrode Placement Perform hand hygiene, don sterile gloves if assess need to do so. Clean the skin with alcohol and then abrade the area with Nuprep.

6. Electrode Placement Place red dots, then apply electrodes

7. Electrode Placement Place red dots, then apply electrodes 1 357 ref 2 4 68 2 6 1 5 4 8 3 7 #7 and #5 are behind the ear

8. Electrode Placement Channel 1 = 1,2 (pink) Channel 2 = 3,4 (blue) Channel 3 = 5,6 (pink) Channel 4 = 7,8 (blue) 135 7 ref 2 4 68 2 6 1 5 4 8 3 7

10. Electrode Placement At a glance TIP: Blue on right…BRRRR, Pink on left…“Pink Lady” (Smoke then fire)

11. Electrode Placement 1.Channel 1: pink (closest to the black electrode) top pink electrode with RED center: A1 placed on LEFT cheek beside LEFT ear bottom pink electrode with BLACK center : FP1 placed on LEFT side of forehead above LEFT eyebrow 2.Channel 2: blue top blue electrode with red center: A2 placed on the RIGHT cheek beside the RIGHT ear bottom blue electrode with black center: FP2 placed on the RIGHT side of the forehead above the RIGHT eyebrow 3.Channel 3: pink top pink electrode with red center: T5 placed directly behind LEFT ear bottom pink electrode with black center: F7 placed on temples just above corner of the eyes 4.Channel 4: blue top blue electrode with red center: T6 placed directly behind the right ear bottom blue electrode with black center: F8 placed on temples just above the corner of the RIGHT eye

12. Monitor Setup Select: “Others” EEG & EP To see EEG page, depress the green comwheel and select EEG, to go back to Normal screen, select “normal screen”

13. Monitor Setup Select: Montage 8, “Mont8” Note: the monitor defaults to “Basic” Montage Type: Bip* Note: this might default to ref. Save Montage *Bip stands for Bipolar – better to view highly localized pattern

14. Monitor Setup Once the CEEG is functioning check to make sure the electrodes are working properly (checking impedance) Press “Others”, scroll to EEG/EP, push wheel, highlight ‘check electrodes” Impedance values are at the bottom of the screen. You should have impedance of less than 5

15. Impedance

16. Troubleshooting If you only see two channels the most common cause is the Montage is “Basic” If the monitor says “leads off” one of your connections is loose If your impedance in > 5.0 skin contact with the red dot is poor

17. Printing All EEG data is saved at the central monitor Go to Full Disclosure, pick your patient and select Neuro You can trace back to find the page that you want to print Select Print Page when you are at the correct selection

18. Let’s hook someone up!

19. Easy waveform analysis Spikes, PLEDS, seizures, burst suppression, artifacts

20. Spikes Spikes look like they would hurt if you sit on them!!

21. Spikes Spikes are to seizures like PVC’s are to v–tach: they show irritability but they do not necessarily mean a patient will have a seizure or go into v-tach

22. PLEDS Periodic Lateral epileptiform discharge Analogy: PLEDS are to seizures like trigeminy is to v-tach. Just because you have PLEDS doesn’t mean you will have a seizure but it means you might be more likely to have one. If you have trigeminy you might be more likely to go into v-tach.

23. PLEDS

24. Seizures Two words you need to remember concerning seizures : EVOLUTION of an electrical RHYTHMIC activity 1 – Increase in amplitude 2 – Decrease in frequency and in amplitude 3 – Post-ictal suppression of the EEG

31. Burst Suppression Commonly seen in anoxic-ischemic encephalopathy and CNS depressant drugs (eg. Midazolam, Propofol)

34. Artifacts Muscle activity Poor electrode Eye movement Chewing

38. Eye Movement

39. Remember… Proper electrode placement is key Review the waveforms frequently and they will get easier to decipher Use your resources (take a printout of a tracing and ask Dr. Young about it) Procedure can be found on the UH ICU website, under procedure EEG monitoring Special Thanks to my model, Savanah!