Telemetry Overview Intern Conference 7/30/13

Transcription

1 Telemetry Overview Intern Conference 7/30/13

2 Indications for Cardiac Monitoring Chest Pain MI Heart Failure Hemodynamically compromised patient Palpitations Syncope Electrolyte /metabolic abnormalities Introduction of proarrythymic or QTc prolonging drug

3 Ordering Telemetry

4

5 Cardiac monitoring level - Adult Cardiac Monitoring Med/Surg: May go off floor without monitor - Adult Cardiac Monitoring Med/Surg: Requires monitor when off floor In general, patients requiring cardiac monitoring when off floor include those patients with the following conditions/situations: Rule out for myocardial infarction pending cardiac enzymes Acute Coronary Syndrome awaiting PCI or CABG who have had chest discomfort or anginal equivalent in prior 24 hrs or who are on IV Ntg, IV Heparin, GPIIbIIIa InhibitorCardiac arrest where the threat of a recurrent arrest remains VT, 2nd /3rd degree HB, AF with rapid ventricular response or any symptomatic dysrhythmias IV Antiarrythymic agents Prolonged QTc than.50 Hemodynamically unstable High flow FiO2 requirement to maintain O2 sats Uncorrected metabolic /electrolyte abnormalities that have potential cardiac effects until these are corrected

6 Alarm Histories

7

8

9

10

11

12

13 Graphics

14

15

16

17 Some Other Tools Full Disclosure Strip Full Disclosure Page

18

19

20 Telemetry Management and Roles

21 RN At the beginning of each shift, the RN runs a rhythm strip and documents rate, rhythm, intervals (PR, QRS, QTc). RN is responsible for reviewing the telemetry data every 4 hours & clearing artifact Managing all alarms Intern Responsible for reviewing telemetry alarms /graphics while pre rounding and circling back during day to look for changes Printing out any significant events and bringing them to rounds (Print out as Event Strip) Reflecting tele data/alarms in Progress Notes, reevaluating decision for telemetry with teams when rounding and reviewing tele order Once patient rules out for example should be discontinued A Discharge Order automatically discontinues telemetry

22

23

24

25 Audible Telemetry Alarms? All audible three tone repetitive alarms are CRISIS ARRYTHYMIA or HR VIOLATION ALARMS RNS responds to alarm immediately Assess whether true clinically significant alarm or whether alarm false (artifact) or clinically not significant to individual patient (2 RN validation, adjust parameter, request house staff change to order) For clinically significant event takes action, notifies MD and documents alarm strip mounting in Progress Note for documentation For clinically significant alarms MD reviews the alarm, discuss with RN and places event note in the chart as to action taken HOUSE STAFF MAY NOT SILENCE ALARMS

26 What You May Be Asked To raise alarm 10 above upper rate To move AF to Message from Advisory To move VT> than 2 to Message is known short runs of NSVT leaving Vent Tach VT>6 To lower low rate to 40

27 To Reflect Change in Order Discontinue the original adult cardiac monitoring order Place new adult cardiac monitoring order incorporating the changes

28 Closing Thoughts

29 Artifact vs V-tach: how can your tell the difference?

30 60 yo woman on ENC 7N with known complete heart block and cancer being followed by EP consult service Pt had a stable escape rhythm and the EP service did not want to put a venous pacer in as she was receiving TPN so were considering arranging for an epicardial pacer

31 Ms. T s Baseline Rhythm

32 At some point the patient began having this on the monitor; what was happening here?

33 14:15 V TACH cont

34 Teaching Points Review Tele Alarms more than just pre-rounds and respond to RN pages about new findings and the alarms they are bringing to your attention. ALWAYS LOOK AND VIEW THE RHYTHM. BE SURE TO SHARE WITH THE RN YOUR ASSESSMENT AND YOUR PLAN AND WHO YOU WILL TELL ABOUT THE RHYTHM If you are unsure if something is artifact, show it to the your Resident, Attending or ask Cardiology for help Remember patients with complete heart block are at increased risk of developing bradycardia dependent torsades from a long QT interval so keep an eye on the QT interval and watch carefully for torsades

35 REMEMBER Alarms belong to all of us. Listen and look up to the the visual signs and monitors when on the units. If you see something alert and check the patient. Thanks!!