EKG

Author Question: Does a Stroke Signal a Monitor Alarm?

/ Jordyn Redwood / Leave a comment

Holly Asks:

When a patient is in the ICU being monitored, are there warning signals (ie beeping noises from machines to alert, etc) right before or after a person has a stroke? In other words, can it come on suddenly and how does the nurse know it’s happening or has happened?

Jordyn Says:

This is a great question. What exactly can a monitor do and not do for a nurse?

When I was still in nursing school, I did an internship in an adult ICU. At first, I would go running to every alarm and, often times, the nurses would stay at the station and analyze what was happening. Then, I never went into the patient’s room and one day– all the nurses went running to help a patient suffering a lethal rhythm. Discerning what is and is not a patient emergency is a learning curve for every healthcare provider and the monitor should be a tool in the toolbox and not the ultimate decision maker.

Generally, when a patient is admitted to the ICU, they are placed on cardiac monitoring. This generally includes an ECG (the heart rhythm), the placement of the chest leads will provide a rough count of breathing (through movement of the chest wall as detected by the leads) and oxygen level (which is the lighted probe placed to a finger.)

These are the basics.

All ICU monitoring systems have a tiered alarm system. Meaning, each heart arrhythmia (and other things) are not treated with the same severity. For instance, a heart rate that falls outside the preset parameters may cause the monitor to signal a repetitive single beep or other tone. A good example of this in pediatrics might be a kid whose heart rate increases due to fever and speeds up outside the preset zone.

When a patient goes into a lethal rhythm, like v-fib, v-tach or asystole, the monitor will triple tone.

A stroke is a brain event. Either bleeding, a clot or ischemia causes the patient to lose certain neurological functions that may include speech, and function of a limb. ONLY if these symptoms were precipitated by other vital sign changes (perhaps a drop in oxygen level due to poor breathing) would the monitor alarm. A stroke may not present with a lethal heart arrhythmia. I think a patient would have to signal a nurse that they are experiencing these symptoms or the nurse may discover the patient has suffered a stroke at a scheduled assessment.

However, if the patient is seizing as a result of the stroke, this could cause the monitor to alarm. The seizure motion shakes the leads and it can resemble v-fib on the monitor even though the patient may still be in a normal rhythm but the monitor doesn’t know the difference so it will alarm. 

So, I would say it is possible for a patient to suffer a stroke without the monitor alarming.

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 Holly Michael has been published in various national magazines, local newspapers, and in Guideposts books. She also worked as a journalist and features writer. Recently, she signed a contract with Harvest House for a devotional book she’s writing with her son, a type one diabetic in the NFL. Holly lives in Kansas City with her husband, who is an Anglican Bishop. She blogs at http://www.writingstraight.com/ Visit her author page at https://www.facebook.com/AuthorHollyMichael

Those Terribly Inaccurate EKG Tracings On Book Covers

/ Jordyn Redwood / Leave a comment

Imagine my surprise when I found someone just as incensed as I was about medical inaccuracy in print but with a different focus. He analyzes book covers. So, I hope you’ll join me in the land of analyzing book covers and discover why nobody’s heart beats this way. Ever.

Welcome, Drew!!

I don’t mean to alarm anyone, but aliens are coming.

As we speak, the Voyager 1 and 2 satellites are crossing the bounds of our solar system into the interstellar medium. Once those spacecraft are discovered by extraterrestrial life forms, they will decipher the code on the Voyager Golden Records allowing them access to the hidden files within, including the location of Earth. The aliens will then return here expecting to find intelligent life, and when we don’t deliver, there will be a reckoning. 
I submit to you, these most egregious book covers:



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How can cholesterol sufferers or aliens trust any of the information in these books when we can’t even be bothered to put a proper heart rhythm on the cover? Now look at these novels:

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Think novels should get a free pass? Think you’ve seen enough? Well just check out these actual ECG training manuals:

     

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The squiggly lines seen on these book covers are supposed to be electrocardiograms (ECGs or EKGs), which are graphical representations of the electrical activity of the heart. Electrical conduction follows very specific pathways through the heart, creating predictable line patterns on the ECG. It is a science, and every ECG you see above is a complete fraud. It is easy for artists to forge ECGs with little or no accuracy, because the general public does not know what a real ECG looks like. For the sake of our planet, it is time we come together to eradicate this scourge. 

The Normal Sinus Rhythm

Many books have been written about the normal structure of various ECG waveforms. It would be impossible to duplicate all of that information here. But we can at the very least cover what a normal ECG should look like: the normal sinus rhythm.

Wikepedia
The whole picture above represents one beat of the heart, and is one sinus heartbeat. The repeating pattern of sinus heartbeats is then referred to as a sinus rhythm. This rhythm is named for the part of the heart where its normal electrical impulse originates, and not for the things in your head that fill up with snot when you’re sick. Each aspect of this beat is labeled with a letter of P through T, and each wave represents a different, specific operation of the heart as it moves through one coordinated beat. You will notice right away that it appears vastly different from any of our previously mentioned book covers. 

There are very specific tolerances for how large or small, wide or narrow each wave can be in a healthy heart. Normally this ECG would be printed on graph paper for ease of measurement, but since we are dealing with art and advertising it is sufficient to be ballpark proportionate. Follow these rules:

1. There is a flat baseline from which the different waves rise and fall. 

2. The first wave is the P wave, which is typically rounded in shape, and smaller than the rest of the waves in the sinus beat.

3. There is a small pause after the P wave.

4. Waves Q, R and S are all lumped together into something called the QRS complex, and the QRS complex is fairly narrow. 

5. There is another small pause after the QRS complex.

6. And finally, the T wave is a rounded wave in shape, and is usually larger than the P wave.

String these together not too close, and not too far apart, and you will have a sinus rhythm with a normal rate of 60-100 beats per minute. To learn more about proper ECG waveform, check out Rapid Interpretation of EKG’s by Dale Dubin, MD. Dr. Dubin makes these ridiculously easy to understand, and you will become an ECG expert in no time. 

In the future, our alien overlords will judge our species by our literature and our art, and we will be punished accordingly. Heed my words people, we must ensure this doesn’t happen by designing our book covers, TV commercials and billboards as accurately as possible. Take some time to study the shape of the normal sinus rhythm. Learn, and correct others who have not yet found the way. The fate of our world is in your hands.
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Drew Rinella is a paramedic and fighter of lost causes. He maintains an archive of bad and wrong ECGs in advertising at http://stupidheartrhythms.blogspot.com. As a free public service, Drew will review your cover art for proper morphology. Email him at drew.rinella@gmail.com.

Shock Me To Death

/ Jordyn Redwood / 2 Comments

There’s nothing like watching a TV show and seeing medical personnel come in with the paddles (even these are rarely used) to shock a patient. Many people say this is “jump-starting” the heart and this is really the wrong clinical picture to give as far as medical accuracy is concerned. The use of electricity on the heart actually stalls it.

What?!?

How could that possibly be helpful to a patient?

Heart cells are very unique, cool little contraptions. Each cell in your heart can generate a beat. Yes, that’s right, every little teeny one. Most often, the normal conduction system of the heart overrides this unique property of heart cells, and the electricity flows from the AV node to the SA node so the heart contracts in a normal, orderly fashion.

Heart Cells: Douglas Cowan, Children’s Hospital Boston
The heart’s normal beat is important because when the top (the atria) contract, it pushes the remaining blood that doesn’t flow via gravity when the valves open into the ventricles. When the ventricles contract, it pushes blood out to the rest of the body.

The purpose of blood flow is really oxygen delivery to the cells. Of course, there are other functions but this is primary. Without oxygen delivery to the cells, cells will die. Lack of oxygen delivery to the cells is called shock.

We’ll talk more about shock in later posts.

Defibrillation (or unsynchronized cardioversion) is only used in a few arrhythmias. Ventricular tachycardia and ventricular fibrillation. These arrhythmias appear when something has affected the heart’s normal conduction system– such as a heart attack, electrical injury, lack of oxygen. They are more common to the adult population than to the pediatric.

In these arrhythmias, the heart’s normal conduction system is no longer working properly and other cells in the heart become active in an attempt to keep the patient alive. The problem with these arrhythmias is that they do not produce a pulse.

No pulse is clinical death. So, we must get back the patient’s pulse back in order for them to have a chance at survival.

What defibrillation actually does is stop the heart by briefly terminating all electrical activity in hopes that the heart’s normal conduction system will begin to work and a palpable pulse will then ensue.

Important note— there must be some electrical activity for defibrillation to work. So, it is not indicated for the treatment of asystole or when the patient has “flatlined”. This is done often in television shows and is a clear medical inaccuracy.

Electricity is also used in another condition called supraventricular tachycardia (SVT). Supra means above. So this rhythm is a very fast rhythm generated somewhere in the atria. Sometimes, when the heart beats incredibly fast, it doesn’t have enough time to fill with blood. When it fills with less blood, it pumps less blood out. Less blood out means less oxygen delivery. The patient can have signs and symptoms of lightheadedness, dizziness, sweating, chest pain, and difficulty breathing to name a few. They still have a pulse though it may be weak and thready.

The goal of using electricity in this instance is again to disrupt this pathway by stalling it in hopes that the heart’s normal conduction system will take over at a much slower rate.

There is also a medication that can be given that will chemically stall the heart, too. It is called adenosine and is used in the stable patient presenting with SVT. It is used in instances of fast rhythms to slow the pulse down.

Does this change your impression of how defibrillation really works?