Rationale for Continuous Cardiac Monitoring and 12-Lead ECG for Mrs. Fenech

QUESTION

In this case study  could you please answer Why it is rationale to give Mrs. Fenech Continuous cardiac monitoring and 12- lead ECG 6th hourly with the last 5 year of peer-reviewed reference?

Introduction: Mrs Mary Fenech is a 78-year-old lady with no known allergies (NKA)

Situation: She arrived in the Emergency Department at 09:30 hrs with slurred speech and right sided weakness since 0530 hrs while at home.

Findings from the CT perfusion assessment using Mean Transit Time (MTT) and Time to Peak (TTP) images showed reduced blood flow in the left middle cerebral artery (MCA) vascular territory extending from the medial cerebellum to the deep white matter at the centrum semiovale above the lateral ventricle. A CT angiogram showed an acute left Internal Carotid Artery (ICA) occlusion. Thrombolysis with Alteplase was administered at 11:30hrs

Background: Atrial Fibrillation (AF), Hypertension (HTN), Type 2 Diabetes Mellitus (IDDM), No head trauma, no prior stroke within the previous 3 months

Regular medications–

Atenolol 50mg daily, Aspirin 100mg daily, Lipitor 40mg daily, Magnesium 200mg daily, Amlodipine 5mg daily, Perindopril 5mg daily, NovoRAPID insulin

Assessment: 

• Airway: slight inspiratory stridor
• Breathing: Respiratory rate 24, bilateral air entry, clear sounds. SpO₂ 90% on room air
• Circulation: BP 149/69, irregular rate – 80 bpm
• Disability: GCS 12 (E 4, V 3, M 5) Pupils equal and reacting to light (PEARL). Sluggish eye gaze. Temp 36.9
• Exposure: x2 IVC in Right & Left cubital fossa
• Fluid: IV Compound sodium lactate (Hartman’s) at 20 mL /hr TKVO
• Glucose blood level: 9.5mmol/L 
• Weight approx. 86kg

Stroke Assessment:

F: Face- Right sided facial droop 

A: Arms- Right sided weakness

S: Speech- Aphasia 

T: Time of onset 0530hrs, Time of thrombolysis 1130hrs, time of ECR planned at 1300hrs, Door-to-Needle time 150 minutes, Symptom to needle time 390 minutes 

Results:  A diagnosis of left MCA stroke with totally occluded left Internal Carotid Artery (ICA)

Nursing Interventions: 

• Initiate Stroke Pathway
• Keep in resuscitation bay (Triage category 2)
• Connect to continuous cardiac monitoring
• Record a 12 lead Electrocardiograph (ECG)
• Initiate supplemental oxygen if SpO2 < 93%
• Monitor airway patency
• Record Glasgow Coma Scale hourly
• Prepare for endovascular clot retrieval (ECR) to restore blood flow
• Arrange for a Speech Pathology consult
• Maintain head of the bed elevated to 30 degrees
• Insert a nasogastric tube
• Maintain nil by mouth
• Collect requested pathology
• Monitor for haematemesis, melaena and haematuria

Blood tests:

Coagulation profile and cross match (PT, APTT, INR), FBC, LFT, EUC,

Medications:

• Alteplase (IV)
• Heparin 5000iu (IV)
• Labetalol
• Insulin NovoRAPID (SC)

ANSWER

Rationale for Continuous Cardiac Monitoring and 12-Lead ECG for Mrs. Fenech

Introduction

Mrs. Mary Fenech, a 78-year-old lady, was admitted to the Emergency Department with slurred speech and right-sided weakness, indicative of a potential stroke. The case presents her medical history, assessment findings, and ongoing interventions. To address the rationale for continuous cardiac monitoring and 12-lead ECG, we will evaluate the significance of these interventions in the context of Mrs. Fenech’s condition.

Rationale for Continuous Cardiac Monitoring

1. Potential Cardiac Causes: Stroke can often be associated with cardiac arrhythmias, particularly atrial fibrillation (AF). AF increases the risk of thrombus formation in the atria, which can embolize to cerebral arteries, causing stroke.
2. Cardioembolic Stroke Risk: Mrs. Fenech’s medical history includes atrial fibrillation and hypertension, both risk factors for cardioembolic stroke. Continuous cardiac monitoring helps detect any arrhythmias that might contribute to her current condition.
3. Arrhythmia Detection: Continuous monitoring allows prompt identification of any new-onset arrhythmias or changes in her heart rhythm, enabling timely intervention.
4. Thrombolysis Risk: Thrombolytic therapy, such as Alteplase, can affect cardiac function and rhythm. Continuous monitoring ensures early detection of potential arrhythmias post-thrombolysis.
5. Treatment Adjustments: The detection of arrhythmias during monitoring can lead to adjustments in medication management and interventions tailored to address specific cardiac issues.

Rationale for 12-Lead ECG

1. Cardiac Ischemia Detection: A 12-lead ECG provides valuable information about cardiac electrical activity and helps identify signs of ischemia or acute myocardial infarction (AMI).
2. Thrombolysis Eligibility: A baseline ECG is essential before initiating thrombolytic therapy like Alteplase. It ensures that no contraindications (e.g., ST-segment elevation indicating AMI) exist for thrombolysis.
3. Arrhythmia Evaluation: The ECG can identify any preexisting or new arrhythmias that might contribute to the patient’s condition or affect treatment choices.
4. Cardiac Function Assessment:The ECG can reveal evidence of atrial fibrillation, which can influence the decision-making process and treatment options.
5. Documentation and Baseline: The initial ECG serves as a baseline for comparison with subsequent ECGs, allowing healthcare providers to track changes in cardiac status over time.

Conclusion

In the case of Mrs. Fenech, continuous cardiac monitoring and a 12-lead ECG are crucial interventions. Continuous cardiac monitoring aids in detecting arrhythmias associated with her stroke risk factors, while a 12-lead ECG provides valuable insights into cardiac electrical activity and ischemic changes. These interventions collectively contribute to comprehensive assessment, early detection, and tailored interventions to optimize her treatment plan.