a. Get the necessary equipment for the procedure

To perform electrocardiogram (ECG) monitoring, it is necessary to select the proper cardiac electrodes and the monitoring unit. Cardiac electrodes, or leads, pick up the electrical signal from a heart contraction and conduct it to the monitor. They are usually called chest leads (or chest electrodes or precordial leads) and consist of four parts: (1) a conducting wire coated with an electrically neutral plastic, (2) an adapter at one end of the wire that plugs into the electrocardiograph machine, (3) a different adapter at the opposite end of the wire that attaches to a patient electrode, and (4) the patient electrode (Figure 11-1, A). Conducting jelly is added to the surface of the electrode to reduce the skin’s resistance to the heart’s electrical signal. An adhesive ring holds the electrode tightly to the skin. The conducting wire snaps or clips onto the back of the electrode. Typically, three to five of these chest leads are used for a period of hours or days for basic rhythm monitoring or Holter monitoring. Typically, three or four chest leads are used for rhythm monitoring. Holter monitoring typically involves using five chest leads.

Figure 11-1 A, Close-up of the features of a prepackaged monitoring electrode or lead. B, Standard electrode placements for lead II monitoring. This results in the traditional-looking electrocardiogram waveform with upright P, QRS, and T waves. (Note: The electrodes are often labeled as right arm [RA] instead of negative pole, left arm [LA] instead of ground electrode, and left leg [LL] instead of positive electrode.)

(From Eubanks DH, Bone RC: Comprehensive respiratory care, ed 2, St Louis, 1990, Mosby.)

One of the following monitoring units must be selected, based on the patient’s situation:

3. Holter monitoring

Holter monitoring involves recording a patient’s complete ECG for 1 to 3 days through the use of a portable, battery-powered monitor. In addition, the patient keeps a diary of any episodes of chest pain, dyspnea, and so forth. The whole system includes the recording device for the patient’s ECG, a set of chest leads, a carrying bag for the recording device, and a patient activity diary (Figure 11-2).

Figure 11-2 Holter monitoring system for ambulatory electrocardiography.

(From Pagana K, Pagana TJ: Mosby’s manual of diagnostic and laboratory tests, ed 3, St Louis, 2006, Mosby.)

a. Put the equipment together and make sure that it works properly.

Connect the patient’s chest leads cable into the proper monitor. Turn on the monitor, and select the desired electrical signal from the heart (usually lead II). Confirm that the electrical signal is displayed on the monitor, and set any alarm limits.

b. Troubleshoot any problems with the equipment.

Successful ECG monitoring requires that the right electrodes be chosen, put together properly, attached to the patient as indicated, and connected to the correct ECG machine. Any errors will result in an electrical signal that is distorted or absent. Recheck all patient electrodes and wire connections if a problem is seen.

a. Get the necessary equipment for the procedure

To perform a diagnostic (also called 12-lead) ECG, get the proper cardiac electrodes and recording electrocardiogram machine. These electrodes will only be use for a few minutes as the recording of the heart’s activity is being done. They come in two sets, one for the limbs and one for the chest.

A 12-lead ECG test requires a machine capable of receiving electrical input from the four limb leads and six precordial leads (see Figures 11-3 and 11-4). The operator can manually select the lead combinations needed to get the 12 different combinations for a 12-lead ECG tracing. However, modern units do this automatically when the operator turns them on. The various ECG combinations are printed out on ECG paper. Modern units also store the patient’s information on a self-contained computer.

Figure 11-3 Limb electrodes or leads properly placed on all four of the patient’s limbs. Make sure that the right leg lead is placed on the right leg, the right arm lead is placed on the right arm, and so forth. The electrode cables are then plugged into the electrocardiograph machine to record the ECG tracings.

(From Eubanks DH, Bone RC: Comprehensive respiratory care, ed 2, St Louis, 1990, Mosby.)

Figure 11-4 Proper placement of the six precordial leads. (See Table 10-1 for a description of the locations.)

(From Eubanks DH, Bone RC: Comprehensive respiratory care, ed 2, St Louis, 1990, Mosby.)

b. Put the equipment together and make sure that it works properly

The limb leads come as a group of four with one for each arm and leg (Figure 11-3). Precordial leads came in a group of six and are placed on the chest in the positions shown in Figure 11-4. A conducting and adhesive jelly is used to reduce the skin’s resistance and to hold the lead in place. The limb leads are longer, and they may need to be held in place by a rubber strap.

c. Troubleshoot any problems with the equipment

Successful ECG monitoring requires that the right electrodes be chosen, put together properly, attached to the patient as indicated, and connected to the correct ECG machine. Any errors will result in an electrical signal that is distorted or absent. With all types of cardiac leads, bad skin contact, dried conducting jelly, or a disconnected wire results in a distorted or absent electrical signal. Recheck all patient electrodes and wire connections if a problem is seen.

a. Review cardiac monitoring data in the patient record (Code: IIB8) [Difficulty: ELE: R; WRE: Ap]

Review the chart of any patient admitted with a significant cardiopulmonary problem for a record of previous cardiac monitoring. Look for a record of rhythm disturbances.

b. Recommend cardiac monitoring (Code: IC9) [Difficulty: ELE: R, Ap; WRE: An]

Recommend cardiac monitoring in any patient with a significant cardiopulmonary problem. This could include, but is not limited to, congestive heart failure, previous myocardial infarction, suspicion of current myocardial infarction, pulmonary embolism, pneumonia, or other problem that could result in serious hypoxemia.

c. Monitor the cardiac rhythm to evaluate the patient’s response to respiratory care (Code: IIIE6) [Difficulty: ELE: R, Ap; WRE: An]

Many hospitalized patients have serious cardiopulmonary problems. The patient may receive supplemental oxygen or inhaled bronchodilator medications. If a possibility exists that the patient will experience significant changes in heart rate or rhythm, he or she should be continuously monitored. This could include patients with serious cardiopulmonary problems, as listed previously. In addition, it could be a patient with an electrolyte disturbance or who is receiving replacement electrolytes intravenously, especially potassium. A bedside rhythm monitoring unit should have an oscilloscope for viewing the rhythm and additional features for counting the heart rate, setting high and low heart rate alarms, and recording the rhythm on standard ECG paper for a permanent record.

The most common chest electrode pattern used for rhythm monitoring is called lead II. The three chest electrodes are placed as shown in Figure 11-1, B. The negative (right arm, RA) electrode is on the right upper chest. The positive (left leg, LL) electrode is placed on the left lateral chest. The ground (left arm, LA) electrode is placed on the left upper chest. With this electrode configuration, known as the Einthoven triangle, the heart’s electrical signal is followed as it flows from the right atrium to the left ventricle. This results in the so-called normal ECG tracing with upright P, R, and T waves, as shown in Figures 11-5 and 11-6. Table 11-1 shows the sequential electrical events of the normal cardiac rhythm that correspond with those in Figure 11-5.

Figure 11-5 Sequence of electrical events of the cardiac cycle during normal sinus rhythm. (See Table 10-2 for the description of each event.)

(From Phillips RE, Feeney MK: The cardiac rhythms: a systematic approach to interpretation, ed 3, Philadelphia, 1990, Saunders.)

Figure 11-6 Timing of the electrical events of the cardiac cycle during normal sinus rhythm.

(From Spearman CB, Sheldon RL, Egan DF: Egan’s fundamentals of respiratory therapy, ed 4, St Louis, 1982, Mosby.)

TABLE 11-1 Electrophysiologic Events Represented by the Electrocardiogram Sequential Electrical Events Electrocardiographic of the Cardiac Cycle Representation

Holter monitoring is done to evaluate noncritical, home care patients with a suspected cardiac problem. Because the patient will be mobile for at least 1 day, the limb leads are placed on the upper and lower chest area. Precordial leads are placed normally. The patient wears a tight-fitting undershirt or netlike dressing to keep the leads in place. The patient cannot bathe while the leads are on.

a. Review electrocardiogram data in the patient record (Code: IB8) [Difficulty: ELE: R; WRE: Ap]

Review the chart of any patient admitted with a significant cardiac problem for a record of a previous electrocardiogram. Look for a record of rhythm disturbances or diagnosis of the problem.

b. Recommend an electrocardiogram to obtain additional data (Code: IC9) [Difficulty: ELE: R, Ap; WRE: An]

A diagnostic electrocardiogram (also called a 12-lead ECG) test is indicated if the patient is suspected of having cardiac problems. Symptoms such as syncope, angina pectoris, sudden crushing chest pain, shortness of breath, or unstable heart rate and blood pressure point to a heart problem. Growing evidence indicates that men and women have different signs and symptoms during an acute myocardial infarction (AMI or MI). Men tend to have crushing central chest pain that may radiate down the left arm or the left side of the neck, diaphoresis, cold extremities, shortness of breath, and a feeling of impending doom. Women tend to experience pain in the lower back and the abdominal area. A diagnostic ECG is indicated to document the nature of the cardiac problem or rule out the heart as a source of the symptoms.

c. Perform a diagnostic electrocardiogram (Code: IB9a) [Difficulty: ELE: R, WRE: Ap, An]

The 12-lead ECG involves the use of an electrocardiograph machine with heat-sensitive ECG recording paper, four limb leads, and six precordial leads (see Figures 11-3 and 11-4). Table 11-2 describes the locations of the precordial leads and the positive and negative electrode combinations that are used to record the heart’s electrical signal through the 12 different leads. Each lead individually records the heart’s electrical activity, but it does so from a different position in relation to the heart. These 12 leads give the physician a three-dimensional impression of how the cardiac conduction system and the myocardium are functioning. Abnormal functioning can be diagnosed. Review the normal anatomy and physiology of the heart and its conduction system, if necessary.

TABLE 11-2 Standard Electrocardiogram Leads

Clinical experience is important in performing a diagnostic ECG. Improper placement of the precordial or limb leads can easily result in a misleading ECG tracing and a misdiagnosis. For example, reversing the arm leads causes the QRS to be reversed in lead I. Technical errors in grounding the patient and not keeping the patient still during the ECG also result in useless tracings because of electrical interference and an unstable baseline.

a. Get the necessary equipment for the procedure

The first consideration when deciding which manual resuscitator to select is the size of the patient. Although the volume of the reservoir bag and the tidal volume expelled from it vary among the types of bags, three basic sizes are available. An infant or newborn unit typically has a reservoir bag volume of about 250 mL. A pediatric unit usually has a reservoir bag volume of about 250 to 500 mL, and an adult unit typically has a reservoir bag volume of 1500 to 2000 mL. In addition to all of these reusable units, a number of disposable units are thrown away after one patient use. They also come in comparable infant, pediatric, and adult reservoir bag volumes.

Any unit should deliver 100% oxygen at the flow rate of 15 L/min. An oxygen reservoir system must be added to the basic unit to achieve these oxygen percentages. The valve to the patient must be clearable within 20 seconds if it becomes fouled by vomitus, sputum, or blood.

Neonatal and pediatric units must have a pressure release (pop-off) valve that opens at 40 cm H₂O pressure. The pressure may be adjustable. If an adult unit has a pressure release valve, it must have an override system that is easy to operate.

b. Put the equipment together and make sure that it works properly

Figure 11-7 shows line drawings of a complete set of Laerdal infant, pediatric, and adult manual resuscitators. The following steps should be taken when the function of a manual resuscitator is evaluated:

Figure 11-7 A, Cutaway drawings of a resuscitation bag showing its features and how the one-way valves open and close during exhalation and inhalation. Note that during exhalation, the patient’s breath is vented to the room and supplemental oxygen is drawn from the reservoir bag into the main bag. To deliver a breath to the patient, the operator squeezes the main bag. This opens the valve to the patient and closes the valve from the reservoir bag. B, Photograph showing an adult, child, and infant resuscitation bag with attached face mask and oxygen reservoir bag. These features are found on all modern units: a self-filling main bag, exhalation valve that does not jam at an oxygen flow of 15 L/min or in subfreezing temperatures (it must be clearable of debris within 20 seconds), intake valve for adding draw room air or supplemental oxygen into the reservoir bag, transparent mask that easily conforms to the patient’s face, pressure relief (pop-off) valve that is set to open at 40 cm water, standard 15-mm inner diameter/22-mm outer diameter connector for the endotracheal tube or face mask, and an oxygen enrichment/reservoir system. In addition, some units have an adjustable positive end-expiratory pressure valve (not shown) attached to the exhalation valve.

(A from Cairo JM, Pilbeam SP: Mosby’s respiratory care equipment, ed 8, St Louis, 2010, Mosby. B courtesy Laerdal Medical, Wappingers Falls, NY.)

c. Troubleshoot any problems with the equipment

Check for a reversed or improperly seated one-way valve (spring-loaded, duckbill, or leaf type) if the gas does not enter or exit the unit as it should. In clinical use, mucus, vomitus, and blood can foul the expiratory one-way valve system. By regulation, the valve must be clearable within 20 seconds. Do this by disconnecting the unit from the patient, aiming the adapter into a neutral area, and squeezing the bag to blow out the obstruction. Replace a unit that cannot be promptly cleared of any debris.

a. Get the necessary equipment for the procedure

The following are important considerations when selecting the best mouth-to-valve device (also called a mouth-to-mask device or pocket mask) for the victim:

b. Put the equipment together and make sure that it works properly

Mouth-to-valve resuscitators are relatively simple devices. Most have only two or three pieces: a face mask, a mouthpiece with a one-way valve, and possibly an oxygen T-piece (Figure 11-8). The “male” and “female” connections are designed to fit together in only one way. When they are properly assembled, no air should leak out when the breath is delivered to the victim.

Figure 11-8 Proper positioning to use a mouth-to-valve mask resuscitator. The top rescuer has added supplemental oxygen to the device. The bottom rescuer is ventilating without the use of added oxygen.

(Courtesy Laerdal Medical Corporation, Wappingers Falls, NY.)

c. Troubleshoot any problems with the equipment

If the breath cannot be delivered, check the one-way valve to make sure that it has not been put together backward. Reverse it, if necessary, and ventilate the victim’s airway. Keep the oxygen nipple on the mask or T-piece capped off if it is not being used. Air will leak out during the delivered breath if the cap is left off the nipple.

a. Establish that the patient is unresponsive and needs cardiopulmonary resuscitation

Observing a patient who appears to be dead does not prove that the patient needs CPR. Clinical death must be proved before CPR is begun. Adults should be tapped or gently shaken while you shout, “Are you okay?” Infants should have the bottom of their feet gently slapped while you shout, “Wake up!” The rescuer also can clap his or her hands together loudly to wake a sleeping infant. CPR should never be started on a person who does not need it.

b. Call out for help

Call out for help if the victim does not respond to any attempts at arousal. The second rescuer should be told to call in the cardiac arrest team. Many hospitals have a cardiac arrest button in each patient’s room. If this is the case, the first rescuer can push the button while calling out for help. Dial 911 if the victim is found at home.

c. Open the airway

The head-tilt/chin-lift maneuver is the procedure of choice for opening the airways of all victims except those with a known or suspected cervical (neck) spine injury. The victim is gently positioned on his or her back. In an adult, the head is firmly pushed back with one hand, and the jaw is pulled upward with the fingers of the other hand (Figure 11-9). In an infant, it is not necessary to tilt the head back beyond a neutral position. Children may need to have the head pushed back slightly beyond neutral.

Figure 11-9 Opening the adult’s airway. Top, Airway obstruction produced by the tongue and epiglottis. Bottom, Relief by head-tilt/chin-lift method.

(From Standards and guidelines for cardiopulmonary resuscitation [CPR] and emergency cardiac care [ECC], JAMA 268:2186, 1992.) Copyright © 1992, American Medical Association. All rights reserved.

The jaw-thrust maneuver is the procedure of choice for opening the airway of all victims with a known or suspected cervical spine injury. The rescuer’s elbows are rested on the ground, and the hands are placed on either side of the victim’s jaw. Lifting of the jaw usually opens the airway and eliminates the need to tilt the head back. See Figure 11-10 for the adult maneuver.

Figure 11-10 Opening the adult’s airway by the jaw-thrust method.

(From Watson MA: Cardiopulmonary resuscitation. In: Barnes TA, editor: Respiratory care practice, St Louis, 1988, Mosby.)

Any obstruction that can be seen in the mouth or throat should be removed. The cross-finger technique can be used to open the mouth wide enough so that a finger or suction device can be inserted to remove a blockage (Figure 11-11). An oral airway should be used only in an unconscious patient to keep the tongue from falling back and blocking the airway.

Figure 11-11 The cross-finger method of opening the victim’s mouth to look for an obstruction.

(From Watson MA: Cardiopulmonary resuscitation. In: Barnes TA, editor: Respiratory care practice, St Louis, 1988, Mosby.)

d. Determine that the patient is not breathing

The rescuer places his or her face close to the victim’s face to look for rising and falling of the chest, listen for victim’s air movement, and feel any air movement from the victim’s breathing (Figure 11-12). The entire procedure should not take longer than 10 seconds.

Figure 11-12 Determining breathlessness by looking, listening, and feeling.

(From Standards and guidelines for cardiopulmonary resuscitation [CPR] and emergency cardiac care [ECC], JAMA 268:2187, 1992.) Copyright © 1992, American Medical Association. All rights reserved.

e. Ventilate the patient

1. Mouth-to-mouth breathing

The first rescuer should begin mouth-to-mouth breathing as soon as possible if no spontaneous breathing by the victim occurs once the airway is opened. No matter the age of the victim, an effective seal must be present between the rescuer and the victim. The adult victim’s nose must be pinched closed; often the rescuer’s cheek can block the infant’s nose. The rescuer’s mouth can cover both the nose and mouth of an infant. Alternative methods include mouth-to-nose and mouth-to-stoma ventilation (Figure 11-13).

Figure 11-13 A, Adult mouth-to-mouth, mouth-to-nose (B), and mouth-to-stoma (C) ventilation.

(From Standards and guidelines for cardiopulmonary resuscitation [CPR] and emergency cardiac care [ECC], JAMA 268:2188, 1992.) Copyright © 1992, American Medical Association. All rights reserved.

In an adult, two breaths large enough to raise the victim’s chest should be given. An adequate volume of 500 to 600 mL may be given. Blow into the victim’s mouth for more than 1 second. This is to ensure a large enough volume without having to use much pressure. Keeping the ventilating pressure as low as possible minimizes the risk of forcing air into the stomach. Ensure that the victim exhales completely by watching the chest fall and feeling the air escape against your cheek. Rescue breathing should be performed at a rate of 10 to 12 times per minute (every 4 to 5 seconds) if the victim has a pulse but is apneic.

A child should be given two breaths large enough to raise the victim’s chest. A child obviously needs less volume than an adult. All of the same considerations apply as for the adult. Rescue breathing should be performed at a rate of 12 to 20 per minute (every 3 to 5 seconds) in an infant and a child. A newly born infant should be ventilated at a rate of 40 to 60 per minute.

If the victim’s airway cannot be ventilated, reposition the head and attempt to ventilate again. Failure to ventilate a second time means that the victim has an obstructed airway. The following steps should be taken:

a. Unconscious adult obstructed airway maneuvers

1. Position. Place the victim on his or her back.

2. Heimlich maneuver. Perform the Heimlich maneuver (also known as abdominal thrusts) several times, if needed, by kneeling astride the victim, placing the heel of one hand midline on the abdomen slightly above the navel, but well below the xiphoid process. The other hand is placed on top, and both are quickly thrust upward toward the chest (Figure 11-14). The rescuer can also perform chest thrusts on the markedly obese or obviously pregnant victim. The rescuer’s hands should be placed on the lower half of the sternum as with cardiac compressions. Several compressions should be performed slowly but similarly to a cardiac compression.

3. Finger sweep. Attempt to clear out any foreign body with a finger sweep. Only attempt this when solid material can be seen in the throat of an unconscious patient. First, grasp the victim’s tongue and jaw between your thumb and fingers, and lift the jaw open. Next, insert the index finger of the other hand along the inside of the victim’s cheek and down the back of the throat so as to hook and remove food, gum, dentures, and so on.

b. Unconscious child (1 year old and older) obstructed airway maneuvers

1. Position. Same as the adult position previously described.

2. Heimlich maneuver. Same as the adult maneuver but with up to five thrusts performed if needed. Chest thrusts are not used.

3. Finger sweep. Only attempt this when solid material can be seen in the throat of an unconscious patient. Remember that blindly inserting the index finger may push a foreign body farther down the throat.

c. Unconscious infant obstructed airway maneuver

1. Position. The infant is straddled over the rescuer’s forearm. The infant’s jaw and head are held by the rescuer’s hand. The infant’s head should be lower than the body. Five firm back blows are delivered between the shoulder blades with the heel of the rescuer’s other hand (Figure 11-15).

2. Heimlich maneuver. The infant is sandwiched by the rescuer’s other arm, and the head and body are supported and turned to a supine position. The head should remain lower than the body. Five chest thrusts are performed in the same location and manner as cardiac compressions but at a slower rate. These steps can be done by placing the infant on the rescuer’s lap.

3. Finger sweep. Same as finger sweep in the unconscious child, mentioned previously.

Figure 11-14 Administering the Heimlich maneuver to an unconscious adult victim of an airway obstruction.

(From Standards and guidelines for cardiopulmonary resuscitation [CPR] and emergency cardiac care [ECC], JAMA 268:2193, 1992.) Copyright © 1992, American Medical Association. All rights reserved.

Figure 11-15 Administering (A) back blows and (B) chest thrusts to an infant victim of an obstructed airway.

(From Standards and guidelines for cardiopulmonary resuscitation [CPR] and emergency cardiac care [ECC], JAMA 268:2258, 1992.) Copyright © 1992, American Medical Association. All rights reserved.

2. Manual resuscitator (bag-valve)

A manual resuscitator should be used during hospital-based CPR as soon as one is available. The resuscitation mask must be held to the victim’s face so that no air leak occurs during the forced inspiration (Figure 11-16). An assistant can hold the mask tightly to the face so that the rescuer who is pumping the resuscitation bag can use both hands. This has been shown to produce a larger tidal volume. If the victim’s airway contains an endotracheal tube or tracheostomy tube, the expiratory valve adapter fits directly over the tube adapter. Rescue breathing continues with the previously mentioned considerations for volume and rate. After an adult victim has had an endotracheal tube placed, the tidal volume goal is 500 to 600 mL over a 1-second period to produce a visible chest rise.

Figure 11-16 Ventilation of an adult with a manual resuscitation bag and mask.

(From Eubanks DH, Bone RC: Comprehensive respiratory care, ed 2, St Louis, 1990, Mosby.)

f. Add supplemental oxygen (ELE code: IIID6) [Difficulty: ELE: R, Ap, An]

The victim should be given 100% oxygen as soon as possible. There is no contraindication for giving pure oxygen during a resuscitation effort. This can be done easily if a manual resuscitator is used to ventilate the victim. All modern units are capable of delivering 100% oxygen when receiving an oxygen flow of at least 10 to 12 liters/minute and a reservoir is added.

g. Determine pulselessness

The carotid pulse is felt for in all victims except children younger than 1 year. The carotid pulse is found by gently feeling with two or three fingers in the groove between the larynx and the sternocleidomastoid muscle on either side of the neck (Figure 11-17). Check for 5 to 10 seconds to be sure that the victim is pulseless and not just bradycardic. In addition, check for other signs of circulation such as spontaneous breathing, coughing, and movement. An infant younger than 1 year should have the pulse felt in the brachial artery; the carotid artery is difficult to find in such young children because they have short, chubby necks.

Figure 11-17 Determining pulselessness by checking the carotid pulse of an adult.

(From Standards and guidelines for cardiopulmonary resuscitation [CPR] and emergency cardiac care [ECC], JAMA 268:2189, 1992.) Copyright © 1992, American Medical Association. All rights reserved.

The femoral pulse can be felt for as an alternative site in victims in the hospital who are wearing few clothes. Once the CPR team has arrived and two-person CPR is instituted, the femoral pulse may be most accessible for monitoring the pulse and the effectiveness of the chest compressions.

h. Perform external chest compressions

The absence of a palpable pulse confirms a cardiac arrest. Blood must be pumped by external chest compressions of the heart. The victim must be supine on a hard surface. A CPR backboard is placed behind a victim who is in bed.

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