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Dysrhythmia Monitoring

• Select the best monitoring leads for dysrhythmia identification (display 2 leads when possible).
  
• Lead V₁ to diagnose wide QRS complex.
  
• Lead II to diagnose atrial activity and measure heart rate.
  
• Proper electrode placement is required for accurate diagnosis (see Figure).
  
• Prepare the patient’s skin before attaching ECG electrodes.
  
• Measure QT interval and calculate QTc using a consistent lead if high risk for Torsades de Pointes.
  

View larger version (75K): [in this window] [in a new window]   Figure Proper electrode placement.

• Studies show that nurses often monitor in a single lead regardless of diagnosis.^1,2
  
• Failure to properly prep skin prior to electrode placement may cause inappropriate monitoring alarms.^3,4
  
• When an electrode is misplaced by as little as 1 intercostal space, QRS morphology can change and misdiagnosis may occur (ie, ventricular tachycardia [VT] may be misidentified as supraventricular tachycardia [SVT] or vise versa).⁵
  

Supporting Evidence

• V₁ is the lead of choice to diagnose wide QRS complexes (VT vs SVT with aberrant conduction; left vs right BBB). A 5-lead monitoring system is required to monitor V leads. MCL₁ may differ in QRS morphology as compared to V₁ and should be used only when a 5 lead monitoring system is unavailable.^6–10 (Level V)
  
• When V₁ electrode placement is not possible, V₆ may be used.^7,11 (Level IV)
  
• Electrode site preparation includes clipping excessive hair and cleansing oily skin with alcohol.^3,4 (Level IV)
  
• QTc >0.50 s (500 ms) is dangerously prolonged and associated with risk for Torsades de Pointes. The QT interval should be corrected for heart rate (QTc) and monitored with any of the following^9,10,12–15: (Level IV)

  – Antidysrhythmic, antibiotic, antipsychotic, and other drugs that prolong QTc
  

  – Severe bradycardia
  

  – Hypokalemia or hypomagnesemia
  

  – Any drug overdose
  

  
  
• Perform an atrial electrogram (AEG) in cardiac surgical patients with atrial epicardial wires to assist in identifying atrial activity.^16,17 (Level V)
  
• Pediatric—Abnormal prolongation: QTc >0.40 s ± 10%. Pediatric limits are age specific and shorter than adult ranges.¹⁸
  

Actions for Nursing Practice

• Ensure that your organization has written policies and procedures related to cardiac monitoring.
  
• Provide appropriate ECG education for staff.
  
• Develop proficiency standards for all staff involved with ECG monitoring to ensure accurate and effective monitoring.
  
• Consider conducting an audit to assess:

  – Electrode placement
  

  – Lead selection
  

  
  

Need More Information or Help?

• An audit tool for measuring compliance with lead selection and lead placement is available at www.aacn.org.
  
• Contact with a clinical practice specialist for additional information/assistance (www.aacn.org, select PRN).
  

AACN Grading Level of Evidence

Level I: Manufacturer’s recommendations only

Level II: Theory based, no research data to support recommendations; recommendations from expert consensus group may exist

Level III: Laboratory data, no clinical data to support recommendations

Level IV: Limited clinical studies to support recommendations

Level V: Clinical studies in more than one or two patient populations and situations to support recommendations

Level VI: Clinical studies in a variety of patient populations and situations to support recommendations.

References

1. Thomason TR, Riegel B, Carlson B, Gocka I. Monitoring electrocardiographic changes: results of a national survey. J Cardiovasc Nurs. 1995;9(4):1–9.[Medline]
2. Drew BJ, Ide B, Sparacino PS. Accuracy of bedside electrocardiographic monitoring: a report on current practices of critical care nurses. Heart Lung. 1991;20(6):597–607.[Medline]
3. Clochesy JM, Cifani L, Howe K. Electrode site preparation techniques: a follow-up study. Heart Lung. 1991;20(1):27–30.[Medline]
4. Medina V, Clochesy JM, Omery A. Comparison of electrode site preparation techniques. Heart Lung. 1989;18(5):456–460.[Medline]
5. Drew BJ. Celebrating the 100th birthday of the electrocardiogram: lessons learned from research in cardiac monitoring. Am J Crit Care. 2002;11(4):378–388.[Abstract/Free Full Text]
6. Drew BJ, Ide B. Differential diagnosis of wide QRS complex tachycardia. Prog Cardiovasc Nurs. 1998;13(3):46–47.[Medline]
7. Drew BJ, Scheinman MM. ECG criteria to distinguish between aberrantly conducted supraventricular tachycardia and ventricular tachycardia: practical aspects for the immediate care setting. Pacing Clin Electrophysiol. 1995;18(12 pt 1):2194–2208.[Medline]
8. Fabius DB. Diagnosing and treating ventricular tachycardia. J Cardiovasc Nurs. 1993;7(3):8–25.[Medline]
9. Drew BJ, Califf RM, Funk M, et al. Practice standards for electrocardiographic monitoring in hospital settings. Circulation. 2004;110(17):2721–2746. http://circ.ahajournals.org/cgi/content/full/110/17/2721. Accessed April 21, 2008.[Abstract/Free Full Text]
10. Drew BJ, Funk M. Practice standards for ECG monitoring in hospital settings: executive summary and guide for implementation. Crit Care Nurs Clin North Am. 2006;18(2):157–168.[Medline]
11. Drew BJ, Scheinman MM, Dracup K. MCL₁ and MCL₆ compared to V₁ and V6 in distinguishing aberrant supraventricular from ventricular ectopic beats. Pacing Clin Electrophysiol. 1991;14(9):1375–1383.[Medline]
12. Passman R, Kadish A. Polymorphic ventricular tachycardia, long Q-T syndrome, and torsades de pointes. Med Clin North Am. 2001;85(2):321–341.[Medline]
13. Crouch MA, Limon L, Cassano AT. Clinical relevance and management of drug-related QT interval prolongation. Pharmacotherapy. 2003;23(7):881–908.[Medline]
14. Sommargren CE, Drew BJ. Preventing torsades de pointes by careful cardiac monitoring in hospital settings. AACN Adv Crit Care. 2007;18(3):285–293.[Medline]
15. Arizona Center for Education and Research on Therapeutics. Drugs that Prolong the QT Interval and/or Induce Torsades de Pointes Ventricular Arrhythmia. 2006. http://www.qtdrugs.org/medical-pros/drug-lists/drug-lists.htm. Accessed April 21, 2008.
16. Kern LS, McRae ME, Funk M. ECG monitoring after cardiac surgery: Postoperative atrial fibrillation and the atrial electrogram. AACN Adv Crit Care. 2007;18(3):294–304.[Medline]
17. Miller JN, Drew BJ. Atrial electrograms after cardiac surgery: Survey of clinical practice. Am J Crit Care. 2007;16(4):350–356.[Abstract/Free Full Text]
18. Mowery B, Suddaby EC. ECG Interpretation: what is different in children? Pediatr Nurs. 2001;27(3): 224–231.[Medline]

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