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Clinical Case - ST changes
Cathy Price CRNAAnne Schools MDJames Philip MD
September 2007
Cathy Price CRNAAnne Schools MDJames Philip MD
September 2007
Clinical Case SummaryPre-op Eval77 yo F for L hip hemi-arthroplastyCAD, Angioplasty in 1993Hypertension, HypercholesterolemiaGastric RefluxFormer SmokerHypothyroidS/P TAH and Bladder suspension, remote
Pre-op Eval77 yo F for L hip hemi-arthroplastyCAD, Angioplasty in 1993Hypertension, HypercholesterolemiaGastric RefluxFormer SmokerHypothyroidS/P TAH and Bladder suspension, remote
Clinical Case Summary
MedicationsDiltiazemLevoxylASAOmeprazoleMetoprolol started in hospital Oxycodone for hip pain in hospital
MedicationsDiltiazemLevoxylASAOmeprazoleMetoprolol started in hospital Oxycodone for hip pain in hospital
Clinical Case
Airway EvalMalampatti III, large overbite, TMD 3 FBOverbiteLarge Anterior Prominent TeethLaboratory ValuesHct 39, INR 1.0, K+ 3.5, Cre 0.5, Lytes nl
Airway EvalMalampatti III, large overbite, TMD 3 FBOverbiteLarge Anterior Prominent TeethLaboratory ValuesHct 39, INR 1.0, K+ 3.5, Cre 0.5, Lytes nl
Pre-Op ECGNSR, possible LAENSR, possible LAE
Clinical Course
Pre-medMidazolam 0.5 mg
InductionRapid SequencePropofol 150 mg, SDC 100 mgEasy Intubation
Pre-medMidazolam 0.5 mg
InductionRapid SequencePropofol 150 mg, SDC 100 mgEasy Intubation
Clinical Course
Post-inductionNIBP 64/40Ephedrine several dosesNIBP 112/61ECG showed ST-T wave abnormalities
Post-inductionNIBP 64/40Ephedrine several dosesNIBP 112/61ECG showed ST-T wave abnormalities
Clinical Course
Clinical concern lead to 12 ECG
Clinical Course
12 lead ECG after Induction to evaluate
Comparison of post-induction ECGsVery different ! Why ?Very different ! Why ?
ECG Filter Problem
James Philip ME(E),MD, CCEJames Philip ME(E),MD, CCE
ECG Filter can be set
Select ECGSelect ECG
Filter window opensFilter window opens
Filter = Diagnostic
DX is OK for perfect signal with no noise or interferenceDX is OK for perfect signal with no noise or interference
Low noise signal
Muscle artifact could look like this
60 Hz (50 Hz UK) Noise from power lines
Wandering baseline looks like thisand needs a filter to keep on screen
The Frequency
Domain
High and Low Frequency components of ECGHigh frequency = rapid changes = jagged: QRS
High and Low Frequency components of ECGHigh frequency = rapid changes = jagged: QRS
High and Low Frequency components of ECGHigh frequency = rapid changes = jagged: QRS
High and Low Frequency components of ECGHigh frequency = rapid changes = jagged: QRS
Low frequency = slow changes = S-T and T
High and Low Frequency components of ECGHigh frequency = rapid changes = jagged: QRS
Low frequency = slow changes = S-T and T
High and Low Frequency components of ECGHigh frequency = rapid changes = jagged: QRS
Low frequency = slow changes = S-T and T
High and Low Frequency components of ECGHigh frequency = rapid changes = jagged: QRS
Low frequency = slow changes = S-T and T
Perfect ECG needs middle and both endsHigh frequency = rapid changes = jagged: QRS
Low frequency = slow change = S-T and T
ECG Filter (= removal)
QRSS-T, T
ECG Filter (= removal)
QRSS-T, T
DIAGNOSTIC
MONITORING
MODERATE
MAXIMUM
ECG Filter (= removal)
QRSS-T, T
DX (.05-100)
MON (.05-40)
MOD (.05-25)
MAX (5-25)
Filter Choices}[ your selection ]
Filter Choices
DIAGNOSTIC — .05Hz to 100Hz - Least filtering. Good for all but myocardial contusion which needs still higher upper end
}[ your selection ]
Filter Choices
DIAGNOSTIC — .05Hz to 100Hz - Least filtering. Good for all but myocardial contusion which needs still higher upper end
MONITORING — .05Hz to 40Hz - Typical monitoring; BWH OR and ICU DefaultEliminates 60 Hz (50 Hz UK) power line artifacts. Retains low frequency signal
}[ your selection ]
Filter Choices
DIAGNOSTIC — .05Hz to 100Hz - Least filtering. Good for all but myocardial contusion which needs still higher upper end
MONITORING — .05Hz to 40Hz - Typical monitoring; BWH OR and ICU Default Eliminates 60 Hz (50 Hz UK) power line artifacts. Retains low frequency signal
MODERATE — .05Hz to 25Hz - Reduces high frequency interference, Including Power Line, ESU, EMG, patient movement
}[ your selection ]
Filter Choices
DIAGNOSTIC — .05Hz to 100Hz - Least filtering. Good for all but myocardial contusion which needs still higher upper end
MONITORING — .05Hz to 40Hz - Typical monitoring; BWH OR and ICU Default Eliminates 60 Hz (50 Hz UK) power line artifacts. Retains low frequency signal
MODERATE — .05Hz to 25Hz - Reduces high frequency interference, Including Power Line, ESU, EMG, patient movement
MAXIMUM — 5Hz to 25Hz - Maximum filtering. Stabilizes ECG baseline. Distorts information in S-T and T waves
}[ your selection ]
Filter Choices
DIAGNOSTIC — .05Hz to 100Hz - Least filtering. Good for all but myocardial contusion which needs still higher upper end
MONITORING — .05Hz to 40Hz - Typical monitoring; BWH OR and ICU Default Eliminates 60 Hz (50 Hz UK) power line artifacts. Retains low frequency signal
MODERATE — .05Hz to 25Hz - Reduces high frequency interference, Including Power Line, ESU, EMG, patient movement
MAXIMUM — 5Hz to 25Hz - Maximum filtering. Stabilizes ECG baseline. Distorts information in S-T and T waves
}[ your selection ]
Upper right corner of screen warns you of 5 Hz minimum freq
Filter Choices
DIAGNOSTIC — .05Hz to 100Hz - Least filtering. Good for all but myocardial contusion which needs still higher upper end
MONITORING — .05Hz to 40Hz - Typical monitoring; BWH OR and ICU Default Eliminates 60 Hz (50 Hz UK) power line artifacts. Retains low frequency signal
MODERATE — .05Hz to 25Hz - Reduces high frequency interference, Including Power Line, ESU, EMG, patient movement
MAXIMUM — 5Hz to 25Hz - Maximum filtering. Stabilizes ECG baseline. Distorts information in S-T and T waves
}[ your selection ]
ST analysis still is correct with no filter
Here, I changed ECG Filter mid-screen
MonitoringMonitoring Maximum FilterMaximum Filter
ECG Filter Settings
ECG Filter = Maximum neverECG Filter = Maximum never
ECG Filter = Moderate when neededECG Filter = Moderate when needed
ECG Filter = Dx or MonECG Filter = Dx or Mon
User Manuals are available on Anesthesia Dept Intranet
http://general.bwh.harvard.edu/intranet/GroupWorkspaces/techmatters/public
Technology matters
Thank you
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