American Journal of Critical Care. 2005;14: 85-86
A regular feature of the American Journal of Critical Care, the ECG Puzzler addresses ECG interpretation for clinical practice. We welcome letters to the Editors regarding this feature.
Bedside Monitoring of Spinal Cord Injuries
By
Mary G. Adams, RN, PhD and
Michele M. Pelter, RN, PhD.
From the School of Nursing at State University of New York at Buffalo (MGA) and Washoe Health System and the School of Nursing, University of Nevada, Reno, NV (MMP).
Scenario: This is a single lead I rhythm strip from the central monitor of a trauma intensive care unit. It was a level one alarm (life-threatening arrhythmia) with the computer interpretation of ventricular tachycardia. The patient is a 20-year-old white woman who sustained a high level (C4) spinal cord injury as an unbelted driver of a motor vehicle accident.
Interpretation: Normal sinus rhythm at 75 beats per minute with a sudden onset artifact.
Rationale
The computer interpretation of ventricular tachycardia is eliminated because the QRS complexes march continuously through the rhythm strip. The differential diagnosis of atrial flutter is also eliminated because atrial flutter does not paroxysmally start within 1 cardiac cycle, then stop and then start again. The registered nurse finds the respiratory therapist at the bedside with the patient, who is wearing a specialized vest that helps clear excess mucus from the lungs of patients with spinal cord injuries. The vest uses a technology called high-frequency chest wall oscillation; during therapy, the vest inflates and deflates rapidly, applying gentle pressure to the chest wall. This works to loosen and thin mucus and move it toward the larger airways, where it can be cleared with suctioning. These external mechanics on the torso have caused this artifact.
Nursing Actions
Respiratory vest therapy is administered for a 15-minute period as often as 4 times a day. Given that respiratory complications are the leading cause of illness and death during the acute phase of spinal cord injury, priority must be given to ensure effective airway clearance. Therefore, clinicians should be aware that during respiratory vest therapy, accurate bedside ECG monitoring is largely compromised; in fact, many of the hemodynamic waveforms are wrought with artifact (see the respiratory waveform on the rhythm strip). Accordingly, before such therapy is initiated, the respiratory therapist should notify the registered nurse to ensure that the patient is hemodynamically stable enough to have compromised monitoring for a 15-minute period.
