Emergencies in the Sleep Lab. Case Studies of real life patients present in the Sleep Lab with Malignant Arrhythmias and Seizures.

Transcription

1 Emergencies in the leep Lab Case tudies of real life patients present in the leep Lab with Malignant Arrhythmias and eizures.

2 Emergency Procedures for Cardiac Arrhythmias During a leep tudy. Ashley Brunette RPGT Henry Ford leep Disorders and Research Center

3 Type of Potential Conflict Details of Potential Conflict Grant/Research upport Consultant peakers Bureaus Financial support Other

4 Cardiac Arrhythmias are among the most common serious adverse events encountered during a sleep study. Even though EKG abnormalities are fairly common during sleep and often benign, the cause for concern is when they occur in association with sleep disordered breathing. According to the AAM, approximately 43% of patients will discover a new (yet to have been diagnosed) EKG abnormality during a sleep study.

5 Common Arrhythmias in leep Tachycardia: an abnormally rapid heart rate (above 100bpms). Bradycardia: an abnormally slow heart rate (generally lower than 60bpms). Premature Ventricular Contractions (PVCs): extra heartbeats that begin in one of the hearts ventricles. Atrial Fibrillation: an irregular and often rapid heart rate where the hearts atria beat out of coordination with the ventricles. Bigeminy: a cardiac rhythm in which each normal beat is followed by an abnormal one (every other beat is abnormal). Trigeminy: a cardiac rhythm that can be two normal beats and one abnormal one OR two PVCs with one normal beat (every third beat is abnormal). Ventricular Tachycardia: an irregular heart rhythm where the ventricles beat very quickly.

6 Normal EKG During leep

7 EKG Emergencies in leep Patient Case tudies

8 Patient #1 53 year old male. Present in leep Lab for a CPAP Titration. History of OA, Type 2 Diabetes (uncontrolled), Hypertension, Coronary Artery Disease, LAD tent (placed in 2016 as a result of a heart attack). Patient arrived at the lab feeling great just tired from a busy day and ready to sleep. Bigeminy was observed during sleep (several occasions). Pt has no previous history of Bigeminy.

9 Patient #1

10 Patient #1

11 Patient #1 Due to several runs of Bigeminy, technologist called the on-call physician. Tech was instructed to transport patient to the emergency room if symptoms and persistence of Bigeminy continues. Runs of Bigeminy continued and therefore patient was transferred to the ER for continuing observation. Patient was asymptomatic but due to concern wished to go to the ER. Patient s study was scored and read and Bigeminy with multiple PVCs was diagnosed.

12 Patient #2 68 year old male. Present in leep Lab for a plit Night tudy. (Participating in leep tudy as part of renal transplant requirements). History of End tage Renal Disease (on peritoneal dialysis), Type 2 Diabetes, CHF, and Hypertension. Patient arrived at the lab feeling good yet tired, but needed to stay awake to start his peritoneal dialysis at midnight. Ventricular Tachycardia (Vtach) was observed on several occasions towards the end of the study (patient did not qualify to split). Patient has no previous history.

13 Patient #2

14 Patient #2

15 Patient #2 Due to several occurrences of Vtach, technologist called the oncall physician. Tech was instructed to transport patient to the emergency room due to his medical history. When technologist entered patients room, patient wished to use the bathroom and did not feel right patient expressed shortness of breath and dizziness (with light headedness). Patient arrived in the ER where under further evaluation more runs of Vtach were observed. Patient s study was scored and read and Ventricular Tachycardia was diagnosed.

16 Patient #3 58 year old female. Present in leep Lab for a Diagnostic tudy. History of Type 2 Diabetes (controlled), Asthma, High Cholesterol and Vertigo. Patient arrived at the lab feeling wide awake but requested to go to bed early due to having to work in the morning. Patient did not have any rhythm abnormalities present on her PG however, patients heart rate was significantly increased at the end of the study (fluctuating between ).

17 Patient #3 Patient woke from her sleep requesting to use the washroom and stated to technologist that she felt dizzy, a shortness of breath and that her chest hurt (tight chested) with fast palpitations. When tech was out of the room patient collapsed on the floor and went into cardiac arrest. Code Blue was called and CPR performed until the medical response team arrived.

18 Patient #3 Patient was taken by the medical response team to the ER. After extensive ER testing it was concluded that the patient had a TEMI (heart attack).

19 Emergency Procedures for eizures During a leep tudy Larry Darnell RPGT Night Lead Tech Henry Ford leep Disorders and Research Center

20 Type of Potential Conflict Details of Potential Conflict Grant/Research upport Consultant peakers Bureaus Financial support Other

21 tates of eizures Prodromal - Changes in feelings, sensations, or even changes in behavior that can happen hours or days before seizure. Aura May be called the focal onset of the seizure. Common symptoms include sensory, emotional, or thought changes. Ictus - The seizure itself, symptoms include, but are not limited to, convulsions, confusion, loss of awareness, rigid body, and a lack of muscle tone. Postictal tate The recovery period after the seizure. ymptoms include, but are not limited to, confusion, memory loss, difficult talking, nausea, head ache or general weakness.

22 Emergency Case tudy s

23 Patient #1 62 year old female. Present in the leep Lab for a Diagnostic tudy (with a parasomnia montage). It was thought that patient s OA could be contributing to her seizures. History of Epilepsy and Nocturnal eizures.

24 Patient #1 hort leep Latency. aturations averaged around 94%. HR in the 60s. 200 epochs into study the seizure began (long respiratory event, saturation drops into the 50s and HR increased to 112bpms).

25 Patient #1 Patient was non-responsive (to verbal or physical stimuli). Rapid Response Team was called and took the patient to the ER. On-call physician was also notified.

26 Patient #2 17 year old male. Present in the lab for a Diagnostic tudy. Patient states that lack of sleep induces his seizures. OA could be the contributing factor to patient s seizures. History of Grand and Petit Mal eizures.

27 Patient #2 Patient s study showed OA events. Patient did not have a seizure during his PG study, but had one prior to taking his morning meds. Patient s convulsions lasted a few minutes and took place on the floor next to the bed was called and the paramedics took the patient to the ER. In the ER, patient was diagnosed with having a grand-mal seizure.

28 Patient #3 27 year old female. Present in the leep Lab for a Diagnostic tudy (to confirm possible OA). History of eizures, ubstance Abuse, Depression and Anxiety. Patient informed the staff that she self medicates with cannabis and did so prior to arriving at the lab.

29 Patient #3 Patient s leep tudy began at 9:30pm (short sleep latency). Around midnight patient woke up and was very confused as to where she was and what was going on. Patient became very anxious. At approximately 1:30am patient had a seizure in bed. Technologist called a Code Blue and the Rapid Response Team took her to the ER.

30 Fall Risk Jayme Hemming RPGT Henry Ford leep Disorders and Research Center

31 Type of Potential Conflict Details of Potential Conflict Grant/Research upport Consultant peakers Bureaus Financial support Other

32 Prevention

33 Assess patients for fall risk at each visit to the leep Disorders and Research Center. Patients identified as a fall risk will have the risk and recommended safety actions documented in the medical record in the clinical encounter and the sleep study order.

34 Risk Assessment A fall risk assessment is a tool used to screen senior adults to determine their risk factors for falling. The risk assessment is generally completed by a care giver, medical professional, or family member.

35 pecify on order Does the patient s physical condition, medical history, or medical profile put him/her at risk for falls? Does the patient have any special needs or require assistance of a caregiver at night? Does the patient have any significant known cardiac, pulmonary, neurological or other co-morbidities or risk factors?

36 Communication is KEY! If unclear, always read through visit encounter.

37 Environmental Resources Accessibility Wheelchairs Canes Bedside comodes Hoyer lifts Clear walk ways

38 What happens if a patient falls?

39 Case tudy 75 year old female having diagnostic sleep study History of Parkinson Disease, Cerebral infraction (stroke), HTN, daytime falls

40 Patient arrives to sleep study via wheelchair. Husband drops her off, stating she does not need a caregiver and manages herself.

41 Tech notices patient is struggling with mobility but patient insists she is ok and does not need assistance. Patient struggled to put on pajamas, tech assisted with putting on shirt.

42 Tech leaves room briefly and comes back to find patient on the ground Patient is conscious and states she fell and hit her head when leaving the bathroom

43 Patient appeared to have bump on her head. Tech called officer to help assist with moving patient to wheel chair and transferring her to the ER. Patient states she usually has a cane, which she did not bring, and had fallen the day before. Filled out RL Risk and Feedback reporting system.

44 What could have been done better? Assessed the patients history Encounter notes uggested caregiver or provided walker when tech observed patient struggling Contacted ER and did not move patient

45 Prevention Communication through encounter notes Observation of wheelchair and patient struggling

46 Remember.. Communication is KEY! Document interaction and observations during sleep study in visit encounter. ALWAY Report the fall within 24 hours via the online RL Risk and Feedback reporting system.

47 Use your resourses Company Policy book Hester Davis Fall Prevention

48 References tfalls.html