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