Cardiac monitoring

Definition The cardiac monitor is a device that shows the electrical and pressure
waveforms of the cardiovascular system for measurement and treatment.
Parameters specific to respiratory function can also be measured. Because
electrical connections are made between the cardiac monitor and the patient, it is
kept at the patient's bedside.

Purpose
The cardiac monitor continuously displays the cardiac electrocardiogram (EKG)
tracing. Additional monitoring components allow cardiovascular pressures and
cardiac output to be monitored and displayed as required for patient diagnosis and
treatment. Oxygen saturation of the arterial blood can also be monitored
continuously. Most commonly used in emergency rooms and critical care areas,
bedside monitors can be interconnected to allow for continual observation of several
patients from a central display. Continuous cardiovascular
and pulmonary monitoring allows for prompt identification and initiation of treatment.

Description
The monitor provides a visual display of many patient parameters. It can be set to
sound an alarm if any parameter changes outside of an expected range determined
by the physician. Parameters to be monitored may include, but are not limited to,
electrocardiogram, noninvasive blood pressure, intravascular pressures, cardiac
output, arterial blood oxygen saturation, and blood temperature.
Equipment required for continuous cardiac monitoring includes the cardiac monitor,
cables, and disposable supplies such as electrodepatches, pressure transducers, a
pulmonary artery catheter (Swan-Ganz catheter), and an arterial blood saturation
probe.

Preparation
As the cardiac monitor is most commonly used to monitor electrical activity of the
heart, the patient can expect the following preparations. The sites selected for
electrode placement on the skin will be shaved and cleaned causing surface
abrasion for better contact between the skin and electrode. The electrode will have a
layer of gel protected by a film, which is removed prior to placing the electrode to the
skin. Electrode patches will be placed near or on the right arm, right leg, left arm, left
leg, and the center left side of the chest. The cable will be connected to the
electrode patches for the measurement of a five-lead electrocardiogram. Additional
configurations are referred to as three-lead and 12-lead electrocardiograms. If
noninvasive blood pressure is being measured, a blood pressure cuff will be placed
around the patient's arm or leg. The blood pressure cuff will be set to inflate
manually or automatically. If manual inflation is chosen, the cuff will only inflate at
the prompting of the health care provider, after which a blood pressure will be
displayed. During automatic operation, the blood pressure cuff will inflate at timed
intervals and the display will update at the end of each measurement.
Disposable pressure transducers require a reference to atmosphere, called zeroing,
which is completed before monitoring patient pressures. This measurement will

Cardiac monitors display such vital signs as heart rate, pulse, and blood pressure for patients in
the intensive care unit. (
Photograph by Hank Morgan. Science Source/Photo Researchers. Reproduced by permission.
)

occur once the patient is comfortably positioned since the transducer must be level
with the measurement point. The pressure transducer will then be connected to the
indwelling catheter. It may be necessary for as many as four or five pressure
transducers to be connected to the patient.
The arterial blood saturation probe will be placed on the finger, toe, ear, or nasal
septum of the patient, providing as little discomfort as possible, while achieving a
satisfactory measurement.

Aftercare
After connecting all equipment, the health care provider will observe the monitor and
evaluate the quality of the tracings, while making size and position adjustments as
needed. The provider will confirm that the monitor is detecting each heartbeat by
taking an apical pulse and comparing the pulse to the digital display. The upper and
lower alarm limits should be set according to physician orders, and the alarm
activated. A printout may be recorded for the medical record, and labeled with
patient name, room number, date, time, and interpretation of the strip.
 Maintenance and replacement of the disposable components may be necessary as
frequently as every eight hours, or as required to maintain proper operation. The
arterial saturation probe can be repositioned to suit patient comfort and to obtain a
tracing. All connections will be treated in a gentle manner to avoid disruption of the
signal and to avoid injury to the patient.

Normal results
The monitor will provide waveforms and/or numeric values associated with the
patient status. These may include, but are not limited to, heart rate, arterial blood
pressure, central venous pressure, pulmonary artery pressure,
pulmonary capillary wedge pressure, left atrial pressure, cardiac output, arterial
blood saturation, and blood temperature. Furthermore, these values can be used to
calculate other values, or parameters, or used to diagnose and treat the patient's
condition.
Patient movement may cause measurement errors; the patient will be requested to
remain motionless. Depending on the mobility of the patient, assistance should be
provided by the health care provider prior to changing from a laying down position to
sitting or standing.
As the patient's condition improves, the amount of monitoring equipment may be
decreased. However, the electrocardiogram and arterial blood saturation probe
should be expect to remain attached until discharge is imminent.

Bedside Cardiac Monitoring

1. Carol Jacobson, RN, MN, CCRN
+ Author Affiliations
1. Carol Jacobson is the director of Quality Education Services, Seattle, Wash.

Q What is the best lead to use for continuous bedside monitoring to detect arrhythmia?

The choice of monitoring lead should be based on the patient’s clinical situation and dictated
by the arrhythmias most likely to occur and be clinically significant for that patient:

 Premature atrial complexes, abnormal sinus rhythms, and most heart blocks, can be recognized in any
lead that displays clear P waves and QRS complexes.

 Atrial fibrillation can be recognized in most leads by the irregular R-R intervals and chaotic atrial
activity that characterize this rhythm.
  When the QRS becomes wide, as it does in bundle branch block, ventricular rhythms, and antegrade
conduction over an accessory pathway, it is very important to choose a lead that best displays the
electrocardiographic criteria used to differentiate wide QRS rhythms.

Research consistently shows that leads V1 and V6 (or their bipolar equivalents MCL1 and MCL6)
are the best leads for differentiating wide QRS rhythms.1–,6 The QRS morphologies displayed in
these leads are invaluable in differentiating ventricular tachycardia from supraventricular
tachycardia with aberrant conduction. Other criteria used in the differential diagnosis, such as
the presence of AV dissociation, QRS width, QRS axis, and the presence of fusion or capture
beats, can be observed in other leads as well. Multiple-lead monitoring is better than single-
lead monitoring, and a 12-lead ECG should be done during the arrhythmia whenever possible.
Q: How do I get lead V1 and V6 on my bedside monitor?
Most newer bedside monitors allow monitoring of 2 leads simultaneously but only allow
monitoring of one precordial (V) lead at a time. Leads V1 or V6 can be obtained by using a 5-lead
bedside monitoring cable with limb electrodes placed as shown in Figure 1⇓:

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Figure 1

Electrode placement for a 5-lead system

 Arm electrodes should be placed on the shoulders as close as possible to where the arms join the torso.
Although the arm electrodes are commonly placed on the anterior shoulder area, placement on the top
or posterior area of the shoulder is also acceptable.

 Leg electrodes should be placed at the level of the lowest ribs on the thorax or on the hips.

 To monitor in lead V1, place the chest electrode in the fourth intercostal space at the right sternal
border and select “V” on the bedside monitor. To obtain V 6, place the chest electrode in the fifth
intercostal space at the left midaxillary line and select “V” on the bedside monitor.
Another option available with a 5-lead system is to monitor lead V1 and the bipolar lead
MCL6 simultaneously by placing the electrodes as shown in Figure 2⇓. The arm electrodes are
placed on the shoulders, the right leg electrode is placed low on the right thorax or right hip,
and the left leg electrode is placed in the V6position (fifth intercostal space, left midaxillary
line). With the electrodes in this position, select “V” on the first channel of the bedside monitor
to display V1, and select lead III on the second channel to display MCL6. This combination of
leads allows an accurate diagnosis of wide complex rhythms 90% of the time.8
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Figure 2
Electrode placement for a 5-lead system, to obtain V1 and MCL6 simultaneously

Q: If our bedside monitors use a 3-lead cable, can we still monitor V1 or V6?
When using a 3-wire cable for monitoring it is not possible to obtain a true unipolar V 1 or
V6 lead. In this case, the bipolar equivalents MCL1 and MCL6 can be recorded by placing
electrodes as shown in Figure 3⇓. Place the right arm electrode on the left shoulder, the left arm
electrode at the V1 position (in the fourth intercostal space at the right sternal border), and
place the left leg electrode in the V6 position (fifth intercostal space at the left midaxillary line).
With electrodes in this position, select lead I on the monitor to obtain MCL 1 and switch to lead II
on the monitor to record MCL6.

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Figure 3

Electrode placement for a 3-lead system

Q: Our bedside monitors use a 5-lead cable and give us a choice of monitoring either V or MCL.
Does it matter which one we choose?

The bipolar leads MCL1 and MCL6 are valid substitutes for their true unipolar counterparts,
V1 and V6, most of the time. However, Drew and Scheinman 5 found that during ventricular
tachycardia, QRS morphology recorded simultaneously in V1 and MCL1 was clearly different 38%
of the time. Monitoring with an MCL lead is acceptable when using a 3-lead system, but is not
recommended when it is possible to obtain a true V lead.7 Therefore, when using a 5-lead
system it is best to select the true V lead.

Q: When should we use ST-segment monitoring?

ST-segment monitoring has become an important part of patient monitoring to detect ischemia
and coronary artery reocclusion in patients who have received thrombolytic therapy or
interventional cardiology procedures such as atherectomy, stents, or rotablation. It is also
useful in detecting silent ischemia and in evaluating chest pain in patients presenting to the
emergency department with atypical pain and nondiagnostic ECGs.

Q: What leads should be used when doing ST-segment monitoring?

Lead selection for ST-segment monitoring depends on the coronary artery involved in the acute
infarction or interventional procedure being performed (see Table).

Most current bedside monitors display only 2 leads simultaneously and allow monitoring of
only one V lead at a time. If lead V1 is used for arrhythmia detection, then a limb lead is the only
choice for ST-segment monitoring. Lead selection for ST-segment monitoring can be facilitated
by noting the patient’s “ischemic fingerprint.” The ischemic fingerprint is the unique pattern
recorded during each patient’s acute ischemic event or when the balloon is inflated during
percutaneous transluminal coronary angioplasty. Choose a lead with maximum ST elevation or
depression recorded during ischemia. If no ischemic fingerprint is available or if maximum ST-
segment deviation occurs in a V lead, leads III and aVF are the best limb leads for monitoring ST
deviation with involvement of all 3 major coronary arteries.9,10
Continuous 12-lead ST-segment monitoring provides a global view of the heart and is the best
choice if it is available. 12-lead monitoring allows the use of all limb leads and all V leads
simultaneously, eliminating the need to rely on limb leads alone for ST-segment monitoring
and avoiding the need to choose the “best” leads for the patient’s clinical situation. Monitoring
using all V leads provides the 2 best arrhythmia detection leads (V 1 and V6) and allows ST-
segment monitoring in V2 and V3 for patients with anterior myocardial infarction or interventions
in the left anterior descending artery.
In summary, the best arrhythmia monitoring lead is V1 (or MCL1); the next best is V6 (or MCL6).
Leads III or aVF are the best limb leads for ST-segment monitoring in the absence of an
ischemic fingerprint to guide lead selection, or in patient’s whose maximum ST deviation occurs
in a V lead. Continuous 12-lead monitoring is the ideal when available.