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Practice Alert Dysrhythmia Monitoring Issued April 2008 Authors & Reviewers: Nancy M. Richards, RN, CNS, MSN, CCRN, CCNS.

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Presentation on theme: "Practice Alert Dysrhythmia Monitoring Issued April 2008 Authors & Reviewers: Nancy M. Richards, RN, CNS, MSN, CCRN, CCNS."— Presentation transcript:

1 Practice Alert Dysrhythmia Monitoring Issued April 2008 Authors & Reviewers: Nancy M. Richards, RN, CNS, MSN, CCRN, CCNS

2 Practice Alert - Dysrhythmia Monitoring 2 Lecture Content  Skin Preparation  Lead Placement  Ventricular Dysrhythmias  QT Intervals

3 Practice Alert - Dysrhythmia Monitoring 3 Skin Preparation  Skin oil and debris can cause noisy signals  Clip excessive hair before placing electrodes  Clean skin with alcohol or washcloth to remove skin oils and/or debris

4 Practice Alert - Dysrhythmia Monitoring 4 Electrode Placement  Limb leads (I,II,III)  Place to decrease muscle artifact during limb movement  Placement  Right Arm (RA) infra-clavicular fossa close to right shoulder  Left Arm (LA) infra-clavicular fossa close to left shoulder  Left Leg (LL) below rib cage on left side of abdomen  Ground (RL) anywhere on torso

5 Practice Alert - Dysrhythmia Monitoring 5 Electrode Placement  Precordial Leads  Dependent on patient’s needs and goals of monitoring  Consider marking electrode location with indelible ink  Ensures electrodes will be placed in same position.  Precordial leads misplaced by 1 ICS can change the QRS morphology

6 Practice Alert - Dysrhythmia Monitoring 6 Dysrhythmia Monitoring  Lead V 1 to distinguish Ventricular Tachycardia (VT) from Supraventricular Tachycardia (SVT) with aberrant conduction  V 1 lead of choice for dysrhythmia monitoring  Lead II or III if patient condition indicates need to monitor for atrial dysrhythmias

7 Practice Alert - Dysrhythmia Monitoring 7 Dysrhythmia Monitoring Lead Placement  V 1 (5 lead system)  4 th intercostal space (ICS) to the right of the sternum  MCL 1 (3 lead system)  4 th intercostal space (ICS) to the right of the sternum

8 Practice Alert - Dysrhythmia Monitoring 8 3 Lead Electrode Placement  Simple 3- electrode lead system  Electrode placement for MCL 1  Only 1 lead can be monitored with a 3 lead system From Philips Cardiac Monitoring Pocket Card 2002

9 Practice Alert - Dysrhythmia Monitoring 9 5 Lead Electrode Placement 5 lead systems allow for the recording of any of the six limb leads plus one precordial (V) lead. Shown lead placement for recording V 1 or V 6. 5 Lead monitoring systems are recommended over 3 lead systems for monitoring QRS morphology From Philips Cardiac Monitoring Pocket Card 2002 V1V1 V1V1 V6V6 V6V6 Angle of Louis

10 Practice Alert - Dysrhythmia Monitoring 10 QRS Morphology Ventricular Tachycardia  V 1 or MCL 1  Monophasic R wave  Notched R wave with taller left peak  Biphasic RS  Biphasic qR  Any of the following in V 1 or V 2  R > 30ms  Slurred or notched S descent  QRS onset to S nadir >60 ms  V 6 or MCL 6  Biphasic rS with R:S ratio <1.0  Monophasic Q  Notched QS  Biphasic qR  Intrinsicoid deflection > 70ms

11 Practice Alert - Dysrhythmia Monitoring 11 QRS Morphology From Philips Cardiac Monitoring Pocket Card 2002

12 Practice Alert - Dysrhythmia Monitoring 12 QRS Morphology SVT with Aberration  V 1 or MCL 1  Bimodal rR’ or triphasic rsR’  All of the following in V 1 or V 2  R < 30 ms or no R  Straight S descent  QRS onset to S nadir < 60 ms and no Q in V 6  V 6 or MCL 6  Triphasic qRs with R:s ratio > 1.0  Intrinsicoid deflection < 50 ms

13 Practice Alert - Dysrhythmia Monitoring 13 QRS Morphology From Philips Cardiac Monitoring Pocket Card 2002

14 Practice Alert - Dysrhythmia Monitoring 14 QRS Morphology Not Helpful  V 1 or MCL 1  R slurred or notched with taller right peak  V 6 or MCL 6  Monophasic R  Notched R with taller left or right peak  Biphasic Rs with R:S ratio > 1.0 Applies only to tachycardias with a positive waveform in V 1

15 Practice Alert - Dysrhythmia Monitoring 15 QRS Morphology From Philips Cardiac Monitoring Pocket Card 2002

16 Practice Alert - Dysrhythmia Monitoring 16 Accurate Lead Placement V1V1 II V1V1 I (A) Onset of wide QRS complex tachycardia shows a “taller right peak” pattern in lead V 1, which is unhelpful in distinguishing between ventricular tachycardia and supraventricular tachycardia with aberrant conduction. Examination of the patient revealed that the V 1 electrode was misplaced to the 5th, rather than the 4th intercostal space ( B) After lead placement was corrected, another episode of wide QRS complex tachycardia showed the “taller left peak” pattern in lead V 1 which is strongly suggestive of ventricular tachycardia (Wellens, et al 1978). Subsequent invasive cardiac electrophysiologic study confirmed the patient had ventricular tachycardia. Used with permission of Barbara J. Drew RN, PhD

17 Practice Alert - Dysrhythmia Monitoring 17 QT Interval  Approximate measure of the duration of ventricular repolarization.  Measured from the beginning of the Q wave to the end of the T wave  Varies with heart rate  Lengthens with bradycardia  Shortens with tachycardia

18 Practice Alert - Dysrhythmia Monitoring 18 QT Interval Measure from beginning of the QRS complex to the end of the T wave From Philips Cardiac Monitoring Pocket Card 2002

19 Practice Alert - Dysrhythmia Monitoring 19 QTc Interval  QT interval corrected for heart rate (QTc)  Formula for calculating QTc (Bazett’s formula)  QTc > 0.50 seconds considered dangerously prolonged and is associated with a higher risk of Torsades de Pointes.

20 Practice Alert - Dysrhythmia Monitoring 20 Measuring the QTc Measure the QT of the second complex used in R – R measurement. Using Bazett’s formula: QTc = 0.36 / √0.72 = 0.36 / 0.85 = 0.42 QTc = 0.42 QT = 0.36 R – R = 0.72

21 Practice Alert - Dysrhythmia Monitoring 21 Torsades de Pointes  Polymorphic Ventricular Tachycardia  Precipitated by prolonged QT interval  Not responsive to and may be exacerbated by class Ia and some Ic medications

22 Practice Alert - Dysrhythmia Monitoring 22 Arrhythmias associated with prolonged QT interval that place the patient at immediate risk for developing torsades de pointes. ECG characteristics include underlying prolonged QT interval, T wave alternans, polymorphic ventricular premature beats that fall near the T-U portion of repolarization, pause-dependent enhancement of the QT interval (arrow), and non-sustained polymorphic ventricular tachycardia. Pause Used with permission of Barbara J. Drew RN, PhD

23 Practice Alert - Dysrhythmia Monitoring 23 Torsades de Pointes  Monitor QT interval for patients identified at high risk:  Patients on medications known to prolong QT interval  Quinidine, procainaminde, disopyraminde, sotalol, dofetilide, ibutilide  For more information see: drug-list.cfm  Patients who overdose on potentially pro- dysrhythmic medications  New onset bradycardia  Severe hypokalemia or hypomagnesemia

24 Practice Alert - Dysrhythmia Monitoring 24 Treatment Emergency IV Magnesium Defibrillation Overdrive pacing Long Term Monitor QTc interval Discontinue or modify drug dose if QTc interval increases > 0.50 secs

25 Practice Alert - Dysrhythmia Monitoring 25 For more information or further assistance, please contact a clinical practice specialist with the AACN Practice Resource Network. Phone: (800) Need Further Assistance?


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