S

Emergencies in the

Sleep Lab Case Studies of real life patients present in the Sleep Lab with Malignant

Arrhythmias and Seizures.

S

Emergency Procedures

for Cardiac Arrhythmias

During a Sleep Study.

Ashley Brunette RPSGT

Henry Ford Sleep Disorders and Research

Center

Type of Potential Conflict Details of Potential Conflict

Grant/Research Support

Consultant

Speakers’ Bureaus

Financial support

Other

S 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 AASM, approximately 43% of patients will

discover a new (yet to have been diagnosed) EKG abnormality

during a sleep study.

Common Arrhythmias in Sleep

S Tachycardia: an abnormally rapid heart rate (above 100bpms).

S Bradycardia: an abnormally slow heart rate (generally lower than 60bpms).

S Premature Ventricular Contractions (PVCs): extra heartbeats that begin in one of the hearts ventricles.

S Atrial Fibrillation: an irregular and often rapid heart rate where the hearts atria beat out of coordination with the ventricles.

S Bigeminy: a cardiac rhythm in which each normal beat is followed by an abnormal one (every other beat is abnormal).

S 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).

S Ventricular Tachycardia: an irregular heart rhythm where the ventricles beat very quickly.

Normal EKG During Sleep

EKG Emergencies in Sleep

Patient Case Studies

Patient #1

S 53 year old male.

S Present in Sleep Lab for a CPAP Titration.

S History of – OSA, Type 2 Diabetes (uncontrolled), Hypertension, Coronary Artery Disease, LAD Stent (placed in 2016 as a result of a heart attack).

S Patient arrived at the lab feeling “great” just tired from a busy day and ready to sleep.

S Bigeminy was observed during sleep (several occasions). Pt has no previous history of Bigeminy.

Patient #1

Patient #1

Patient #1

S Due to several runs of Bigeminy, technologist called the on-call physician.

S Tech was instructed to transport patient to the emergency room if symptoms and persistence of Bigeminy continues.

S Runs of Bigeminy continued and therefore patient was transferred to the ER for continuing observation.

S Patient was asymptomatic but due to concern wished to go to the ER.

S Patient’s study was scored and read and Bigeminy with multiple PVCs was diagnosed.

Patient #2

S 68 year old male.

S Present in Sleep Lab for a Split Night Study. (Participating in Sleep Study as part of renal transplant requirements).

S History of – End Stage Renal Disease (on peritoneal dialysis), Type 2 Diabetes, CHF, and Hypertension.

S Patient arrived at the lab feeling “good” yet tired, but needed to stay awake to start his peritoneal dialysis at midnight.

S 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.

Patient #2

Patient #2

Patient #2

S Due to several occurrences of Vtach, technologist called the on-call physician.

S Tech was instructed to transport patient to the emergency room due to his medical history.

S 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).

S Patient arrived in the ER where under further evaluation more runs of Vtach were observed.

S Patient’s study was scored and read and Ventricular Tachycardia was diagnosed.

Patient #3

S 58 year old female.

S Present in Sleep Lab for a Diagnostic Study.

S History of – Type 2 Diabetes (controlled), Asthma, High Cholesterol and Vertigo.

S Patient arrived at the lab feeling “wide awake” but requested to go to bed early due to having to work in the morning.

S Patient did not have any rhythm abnormalities present on her PSG however, patients heart rate was significantly increased at the end of the study (fluctuating between 125-155).

Patient #3

S 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.

S When tech was out of the room patient collapsed on the floor and went into cardiac arrest.

S Code Blue was called and CPR performed until the medical response team arrived.

Patient #3

S Patient was taken by the medical response team to the

ER.

S After extensive ER testing it was concluded that the

patient had a STEMI (heart attack).

S

Emergency Procedures

for Seizures During a

Sleep Study

Larry Darnell RPSGT Night Lead Tech

Henry Ford Sleep Disorders and Research Center

Type of Potential Conflict Details of Potential Conflict

Grant/Research Support

Consultant

Speakers’ Bureaus

Financial support

Other

States of Seizures

S Prodromal - Changes in feelings, sensations, or even changes

in behavior that can happen hours or days before seizure.

S Aura – May be called the focal onset of the seizure. Common

symptoms include sensory, emotional, or thought changes.

S Ictus - The seizure itself, symptoms include, but are not limited

to, convulsions, confusion, loss of awareness, rigid body, and a

lack of muscle tone.

S Postictal State – The recovery period after the seizure.

Symptoms include, but are not limited to, confusion, memory

loss, difficult talking, nausea, head ache or general weakness.

Emergency Case

Study’s

Patient #1

S 62 year old female.

S Present in the Sleep Lab for a Diagnostic Study (with a

parasomnia montage). It was thought that patient’s OSA

could be contributing to her seizures.

S History of – Epilepsy and Nocturnal Seizures.

Patient #1

S Short Sleep Latency.

S Saturations averaged around 94%.

S HR in the 60s.

S 200 epochs into study the seizure began (long respiratory

event, saturation drops into the 50s and HR increased to

112bpms).

Patient #1

S Patient was non-responsive (to verbal or physical stimuli).

S Rapid Response Team was called and took the patient to

the ER. On-call physician was also notified.

Patient #2

S 17 year old male.

S Present in the lab for a Diagnostic Study. Patient states

that lack of sleep induces his seizures.

S OSA could be the contributing factor to patient’s seizures.

S History of – Grand and Petit Mal Seizures.

Patient #2

S Patient’s study showed OSA events.

S Patient did not have a seizure during his PSG study, but had one prior to taking his morning meds.

S Patient’s convulsions lasted a few minutes and took place on the floor next to the bed.

S 9-11 was called and the paramedics took the patient to the ER.

S In the ER, patient was diagnosed with having a grand-mal seizure.

Patient #3

S 27 year old female.

S Present in the Sleep Lab for a Diagnostic Study (to

confirm possible OSA).

S History of – Seizures, Substance Abuse, Depression and

Anxiety.

S Patient informed the staff that she self medicates with

cannabis and did so prior to arriving at the lab.

Patient #3

S Patient’s Sleep Study began at 9:30pm (short sleep latency).

S Around midnight patient woke up and was very confused as to

where she was and what was going on.

S Patient became very anxious.

S At approximately 1:30am patient had a seizure in bed.

S Technologist called a Code Blue and the Rapid Response

Team took her to the ER.

S

Fall Risk

Jayme Hemming RPSGT

Henry Ford Sleep Disorders and Research Center

Type of Potential Conflict Details of Potential Conflict

Grant/Research Support

Consultant

Speakers’ Bureaus

Financial support

Other

Prevention

Assess patients for fall risk at each visit to the Sleep

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.

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.

Specify on order

S Does the patient’s physical condition, medical history, or

medical profile put him/her at risk for falls?

S Does the patient have any special needs or require

assistance of a caregiver at night?

S Does the patient have any significant known cardiac,

pulmonary, neurological or other co-morbidities or risk

factors?

Communication is KEY!

S If unclear, always read through visit encounter.

Environmental Resources

Accessibility

S Wheelchairs

S Canes

S Bedside comodes

S Hoyer lifts

S Clear walk ways

What happens if a patient

falls?

Case Study

S 75 year old female having diagnostic sleep study

S History of Parkinson Disease, Cerebral infraction (stroke),

HTN, daytime falls

S Patient arrives to sleep study via wheelchair. Husband

drops her off, stating she does not need a caregiver and

manages herself.

S Tech notices patient is struggling with mobility but patient

insists she is ok and does not need assistance.

S Patient struggled to put on pajamas, tech assisted with

putting on shirt.

S Tech leaves room briefly and comes back to find patient

on the ground

S Patient is conscious and states she fell and hit her head

when leaving the bathroom

S 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.

S Patient states she usually has a cane, which she did not

bring, and had fallen the day before.

S Filled out RL Risk and Feedback reporting system.

What could have been done

better?

S Assessed the patients history

S Encounter notes

S Suggested caregiver or provided walker when tech

observed patient struggling

S Contacted ER and did not move patient

Prevention

S Communication through encounter notes

S Observation of wheelchair and patient struggling

Remember.. Communication is

KEY!

S Document interaction and observations during sleep

study in visit encounter.

S ALWAYS Report the fall within 24 hours via the online RL

Risk and Feedback reporting system.

Use your resourses

S Company Policy book

S Hester Davis Fall Prevention

References

S https://www.cdc.gov/homeandrecreationalsafety/falls/adul

tfalls.html

S http://www.personalinjuryhome.com/Glossary/fall-risk-

assessment