S. D Case Study

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S.D. is a 45-year-old woman who comes to the ED complaining of sudden onset of palpitations and shortness of breath. Standard protocol requires you to obtain a 12-lead ECG and attach S.D. to the cardiac monitor for continuous monitoring. A 12-lead ECG recording for S.D is ordered while you print out a rhythm strip from the cardiac monitor.
1. Describe the appropriate location to apply the leads for both the 5-lead cardiac monitor as well as the 12- lead ECG.
- For the 5-lead cardiac monitor, there are five electrode pads placed. The RA electrode (white) is placed below the right clavicle (2nd interspace, right midclavicular line), the LA (black) is placed below the left clavicle (2nd interspace, left midclavicular line), the RL ( green) is
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5. What treatment might you expect the health care provider to initially order for S.D.’s atrial fibrillation?
- The goals of treatment include a decrease in ventricular response (to less than 100 beats/minute), prevention of stroke, and conversion to normal sinus rhythm, if possible. To accomplish this, I would expect the health care provider to initially order drugs to control the ventricular rate, such as calcium channel blockers, beta-adrenergic blockers, digoxin, and dronedarone. For some patients, pharmacologic or electrical conversion of the atrial fibrillation to normal sinus rhythm may then also be considered, such as by using amiodarone or electrical cardioversion. If the atrial fibrillation lasts for longer than 48 hours, anticoagulation therapy will be needed for 3-4 weeks before the cardioversion and for weeks after as well. If drugs or cardioversion do not work, radiofrequency catheter ablation and the Maze procedure would be expected as further options.
S.D. was admitted to the telemetry unit and an IV amiodarone drip was started. The purpose of the drug was to convert her atrial fibrillation to normal sinus rhythm. Although her heart rate has decreased to 108 beats/minute, she remains in atrial fibrillation 24 hours later. A cardiologist was consulted and electrical cardioversion is
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What specific ECG change will you be looking for to determine if S.D.’s chest pain is related to cardiac ischemia? Injury? Infarction?
- To determine if the patient’s chest pain is related to cardiac ischemia, you would look for ST-segment depression and/or T wave inversion. If the ST-segment depression is at least 1mm (one small box) below the isoelectric line, it is significant and occurs in response to inadequate supply of blood and oxygen, which leads to an electrical disturbance. Once this is treated, adequate blood flow is restored, the ECG changes will resolve, and the ECG will return back to patient’s baseline.
To determine if the patient’s chest pain is related to injury, you would look for ST-segment elevation. Myocardial injury represents a worsening stage of ischemia. If ST-segment elevation is greater than or equal to 1mm above the isoelectric line, it is significant and treatment needs to be prompt and effective to try to restore oxygen to the myocardium, and to avoid or limit infarction. The absence of serum cardiac markers confirms that infarction has not
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