Telemetry
Overview
Intern
Conference 7/30/13
Indications for Cardiac
Monitoring
Chest Pain
MI
Heart Failure
Hemodynamically compromised patient
Palpitations
Syncope
Electrolyte /metabolic abnormalities
Introduction of proarrythymic or QTc prolonging drug
Ordering Telemetry
Cardiac monitoring level
- Adult Cardiac Monitoring Med/Surg: May go off floor without
monitor - Adult Cardiac Monitoring Med/Surg: Requires monitor when
off floor
In general, patients requiring cardiac monitoring when off
floor include those patients with the following
conditions/situations:
Rule out for myocardial infarction pending cardiac enzymes
Acute Coronary Syndrome awaiting PCI or CABG who have
had chest discomfort or anginal equivalent in prior 24 hrs or
who are on IV Ntg, IV Heparin, GPIIbIIIa InhibitorCardiac
arrest where the threat of a recurrent arrest remains
VT, 2nd /3rd degree HB, AF with rapid ventricular response or
any symptomatic dysrhythmias
IV Antiarrythymic agents
Prolonged QTc ≥ than .50
Hemodynamically unstable
High flow FiO2 requirement to maintain O2 sats
Uncorrected metabolic /electrolyte abnormalities that have
potential cardiac effects until these are corrected
Alarm Histories
Graphics
Some Other Tools
Full Disclosure Strip
Full Disclosure Page
Telemetry Management
and Roles
RN At the beginning of each shift, the RN runs a rhythm strip and
documents rate, rhythm, intervals (PR, QRS, QTc).
RN is responsible for reviewing the telemetry data every 4 hours & clearing artifact
Managing all alarms
Intern Responsible for reviewing telemetry alarms /graphics while
pre rounding and circling back during day to look for changes
Printing out any significant events and bringing them to rounds (Print out as Event Strip)
Reflecting tele data/alarms in Progress Notes , reevaluating decision for telemetry with teams when rounding and reviewing tele order
Once patient rules out for example should be discontinued
A Discharge Order automatically discontinues telemetry
Audible Telemetry Alarms?
All audible three tone repetitive alarms are CRISIS ARRYTHYMIA or HR VIOLATION ALARMS RNS responds to alarm immediately Assess whether true clinically significant alarm or whether alarm false (artifact) or clinically not significant to individual patient (2 RN validation, adjust
parameter, request house staff change to order) For clinically significant event takes action, notifies MD
and documents alarm strip mounting in Progress Note for documentation
For clinically significant alarms MD reviews the alarm, discuss with RN and places event note in the chart as to action taken
HOUSE STAFF MAY NOT SILENCE ALARMS
What You May Be Asked
To raise alarm 10 above upper rate
To move AF to Message from Advisory
To move VT> than 2 to Message is known
short runs of NSVT leaving Vent Tach VT>6
To lower low rate to 40
To Reflect Change in Order
Discontinue the original adult cardiac
monitoring order
Place new adult cardiac monitoring order
incorporating the changes
Closing Thoughts
Artifact vs V-tach: how can your
tell the difference?
60 yo woman on ENC 7N with known
complete heart block and cancer being
followed by EP consult service
Pt had a stable escape rhythm and the EP
service did not want to put a venous pacer
in as she was receiving TPN – so were
considering arranging for an epicardial
pacer
Ms. T’s Baseline Rhythm
At some point the patient began having this on the monitor;
what was happening here?
14:15 “V TACH” cont…
Teaching Points Review Tele Alarms more than just pre-rounds and
respond to RN pages about new findings and the alarms they are bringing to your attention. ALWAYS LOOK AND VIEW THE RHYTHM. BE SURE TO SHARE WITH THE RN YOUR ASSESSMENT AND YOUR PLAN AND WHO YOU WILL TELL ABOUT THE RHYTHM
If you are unsure if something is artifact, show it to the your Resident , Attending or ask Cardiology for help
Remember patients with complete heart block are at increased risk of developing bradycardia dependent torsades from a long QT interval – so keep an eye on the QT interval and watch carefully for torsades
REMEMBER Alarms belong to all of us . Listen and look up to the
the visual signs and monitors when on the units . If you see something alert and check the patient.
Thanks!!