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Issued April 2008Issued April 2008
Authors & Reviewers:Authors & Reviewers:
Karen L Johnson, RN, MSN, PhDKaren L Johnson, RN, MSN, PhDKate M. Moore, RN, MS, ND, CCRN, ACNPKate M. Moore, RN, MS, ND, CCRN, ACNP
Practice AlertPractice AlertST Segment MonitoringST Segment Monitoring
Practice Alert - ST Segment Monitoring2
Lecture Content
Skin preparation Lead placement and selection Patient positioning Measuring the ST segment Pediatric specific Recommendations
Practice Alert - ST Segment Monitoring3
Skin Preparation
Clip excessive hair before placing electrodes
Clean skin with alcohol or washcloth to remove skin oils and/or debris
Mark locations with indelible ink to assure that if electrodes are moved they can be replaced in their original locations.
Practice Alert - ST Segment Monitoring4
Electrode Placement
Limb leads (I,II,III)Place to decrease muscle artifact during limb
movementPlacement
Right Arm (RA) infra-clavicular fossa close to right shoulder
Left Arm (LA) infra-clavicular fossa close to left shoulder
Left Leg (LL) below rib cage on left side of abdomenGround (RL)
Precordial Leads - depends on patient’s needs
Practice Alert - ST Segment Monitoring5
ST Segment Monitoring
ST segment monitoring can detect silent ischemia in asymptomatic patients.
Although the impact of ST segment monitoring on patient outcomes is not known, when ST segment monitoring is used, it is imperative that accurate data are obtained.
Practice Alert - ST Segment Monitoring6
Lead Selection
Monitoring ST segment changes in 12 leads provides the most accurate data for identification of ischemic events.
If only two leads are available for ST segment monitoring, use leads III and V3 (unless otherwise indicated)
Practice Alert - ST Segment Monitoring7
ST Segment Fingerprint
If 12 lead monitoring is not available, use the patient’s “ST Fingerprint”.
Defined as the pattern of ST segment elevation and/or depression unique to a particular patient based on the anatomic site of coronary occlusion
Can be obtained during STEMI or PCI
Practice Alert - ST Segment Monitoring8
Other Considerations
If the ST fingerprint is not known, use leads III and V3.
For patients without definitive ACS, with suspected of having or being ruled out for ACS, use leads III and V5.
For non-cardiac surgical patients lead V5 is valuable for identifying demand-related ischemia.
Practice Alert - ST Segment Monitoring9
Patient Positioning
Evaluate ST segment with the patient in the supine position.
Change in body position can alter ST segment, mimic ischemia.
If ST alarm sounds with patient in side-lying position, return patient to supine. If deviation persists in supine may indicate ischemia.
Practice Alert - ST Segment Monitoring10
Measuring the ST Segment
J PointThe junction of
the QRS complex with the ST segment
Measure ST segment changes 60 ms beyond the J point
Flanders SA. Continuous ST-segment monitoring: Raising the bar. Crit Care Nurs Clin N Am 2006;18(3):172
Practice Alert - ST Segment Monitoring11
Alarm Parameters
Patients at high risk for ischemiaSet ST segment alarm
parameters 1 above and below baseline ST segment
Stable PatientsSet ST segment alarm
parameters 2 mm above and below baseline ST segment
Practice Alert - ST Segment Monitoring12
Cause for Concern
ST depression or elevation of 1-2 mm that lasts for at least one minute can be clinically significant and warrants further patient assessment.
Flanders SA. Continuous ST-segment monitoring: Raising the bar. Crit Care Nurs Clin N Am 2006;18(3):172
5 mm depression5 mm depression 4 mm elevation4 mm elevation
Practice Alert - ST Segment Monitoring13
Pediatric Specific Information
For neonates and infants the TP segment may be a more accurate isoelectric point than the PR segment.
For neonates and infants an ST elevation or depression of 1 mm or greater is considered clinically significant.
Practice Alert - ST Segment Monitoring14
Need Further Assistance?
For more information or further assistance, please contact a clinical practice specialist with the AACN Practice Resource Network.
Email:[email protected]
Phone:
(800) 394-5995