Podcast with Dr. Kossick

Transcription

1 Podcast with Dr. Kossick Interviewed by Western Carolina University Graduate Anesthesia Student Kristin Andrejco From the Head of the Bed December 5, 2014 (33 min) EKG Lead Selection for Perioperative Monitoring Mark A. Kossick, DNSc, CRNA, APN Tenured Professor Graduate Anesthesia Simulation Coordinator School of Nursing High Fidelity Simulation Center College of Health and Human Sciences Western Carolina University Asheville, North Carolina Rev

2 Copyright 2015 by Mark A. Kossick, DNSc, CRNA, APN. All rights reserved. No part of this PowerPoint handout may be reproduced in any form or by any means, electronic, mechanical, including photocopy, or any information storage and retrieval systems, without permission in writing from the author

3 Correct EKG Lead Placement The literature demonstrates... Nurses who routinely monitor ECG have consistent problems with - EKG electrode placement EKG lead configuration In a 1991 study it was found that of 138 nurses who were members of the American Association of Critical-Care Nurses 87% demonstrated incorrect technique in setting up their two leads of choice these monitors had five-lead-wire cables 93% of those nurses having done so by misplacing their EKG electrodes Drew BJ, Ide B, Sparacino PS. Accuracy of bedside electrocardiographic monitoring: a report on current practices of critical care nurses. Heart & Lung. 1991;20(6):

4 Mason-Likar Lead Configuration Torso-position electrode configuration Limb leads are placed on the body torso Developed for exercise testing to reduce noise levels, reduces false alarms due to a noisy signal when the patient/surgeon moves the extremities Place arm electrodes as close to shoulders as possible (or outer clavicles) to minimize differences between this lead configuration and the standard 12-lead Not considered equivalent to the standard 12 lead ECG

5 EKG Electrode Placement (Limb Leads) RA, LA, LL EKG electrodes Placed over bony prominences near junction appendages and torso Helps to avoid skeletal muscle artifact Stabilizes EKG tracing Alternative for placement lower limb (LL) electrode More proximal in lumbar region ie, anterior axillary line ½ way between iliac crest and costal margin Lower lateral chest wall ie, anterior axillary line, 6 th ICS Avoid whenever possible more medial placement RL electrode can be placed in any convenient location

6 V 5 is horizontal to V 4- not 5 th intercostal space Bipolar Precordial Chest Leads True Chest Leads Reprinted with permission from Kossick MA. Recognizing EKG evidence of ischemia, injury, and infarction. In: EKG Interpretation: Simple, Thorough, Practical. 3rd ed. Park Ridge, IL: AANA Publishing. In press.

7 th intercostal space Reprinted with permission from Kossick MA. Recognizing EKG evidence of ischemia, injury, and infarction. In: EKG Interpretation: Simple, Thorough, Practical. 3rd ed. Park Ridge, IL: AANA Publishing. In press.

8 V 2 V 3 V 4 Reprinted with permission from Kossick MA. Recognizing EKG evidence of ischemia, injury, and infarction. In: EKG Interpretation: Simple, Thorough, Practical. 3rd ed. Park Ridge, IL: AANA Publishing. In press.

9 Conventional Posterior EKG Leads: V 1-2 Monitor in presence of inferior MI the following true POSTERIOR leads V 7 posterior axillary line V 8 below scapula V 9 paravertebral border Kligfield, P., et al. AHA/ACCF/HRS Recommendations for the standardization and interpretation of the electrocardiogram: part I: The Electrocardiogram and its technology: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society. J Am Coll Cardiol 2007;49:1120.

10 An excellent resource that provides recommendations for standardization and interpretation of the EKG is found in the J Am Coll Cardiol 2007;49:1121 This article is a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society.

11 Three Cable EKG System (Configuring a True Chest Lead V 5 as a Modified Chest Lead) MCL 5 CS 5 RA LA LL Modified Chest Lead V 5 (MCL 5 ) can be configured as a Central Subclavicular 5 (CS 5 ) Reprinted with permission from Kossick MA. Recognizing EKG evidence of ischemia, injury, and infarction. In: EKG Interpretation: Simple, Thorough, Practical. 3rd ed. Park Ridge, IL: AANA Publishing. In press.

12 Central Subclavicular 5 (CS 5 ) is a modification of a true V 5 Reprinted with permission from Kossick MA. Recognizing EKG evidence of ischemia, injury, and infarction. In: EKG Interpretation: Simple, Thorough, Practical. 3rd ed. Park Ridge, IL: AANA Publishing. In press.

13 Landesberg G, et al Anesthesiology 96 (2): , 2002 Perioperative Myocardial Ischemia & Infarction: Identification by Continuous 12-lead Electrocardiogram with Online ST-segment Monitoring 185 consecutive pts undergoing vascular surgery Monitored by continuous 12-lead ST trend analysis during & hrs after surgery use single lead inadequate Two or more appropriate leads (chest leads) 92.1 to 97.4% sensitivity ST depression seen in 97% of all patients V 3 detected ischemia earliest (86.8%) Followed by V 4 (78.9%), then V 5 (65.8%)

14 Landesberg G, et al Anesthesiology 96 (2): , 2002 Perioperative Myocardial Ischemia & Infarction: Identification by Continuous 12-lead Electrocardiogram with Online ST-segment Monitoring With pts sustaining MI V 4 most sensitive (78.9%) V 3 & V 5 equally sensitive (75%) MI diagnosed via Cardiac troponin I levels greater than 3.1 ng/ml Accompanied by symptoms of ischemia or EKG criteria (ST depression or elevation, or pathological Q waves)

15 Major Anesthesia Textbooks Continue to Convey the Benefit of EKG Leads V 3 & V 4 Kossick, M.A., (eds. Nagelhout, J.J. & Plaus, K.L.) Nurse Anesthesia (5 th ed.), Chapter 17 Clinical Monitoring I: Cardiovascular System (p ). Philadelphia: W.B. Saunders (ISBN: ) Landesberg, G., Hillel, Z., (ed. Miller, R. D.) Anesthesia (8 th ed.), Chapter 42- Electrocardiography (p ). Philadelphia: Elsevier Churchill Livingston (ISBN: )

16 EKG Leads Preferred for Monitoring Perioperative Myocardial Ischemia: ST segment depression (subendocardial injury) ST segment elevation (transmural injury) V 3 and V 4 are more sensitive than V 5 Inferior lead III preferred limb lead