Monitoring in V1 and "narrow complex" V Tach

[bigdogems]

So I just took a lecture that was based on the theory of never monitoring your pt in lead II. It was recommended using V1 or modified MCL1. The reasoning was it is easier to identify p waves and bundle branch blocks.... Now here comes the fun part. It was said that it is possible to have a lead II that appears normal and the pt is actually in V Tach. But by looking at changes in V1 it is actually V Tach. The way everything was explained seemed accurate. Heres the problem. After multiple searches I can't find any supporting articles or references to cardiology or EP books that back this up. Now it is printed in 1 Brady 12 lead book and Id like to think Brady wouldn't put out a book with false info. Does anyone else do this or have a medical director that backs this up?

 

[DV_EMT]

Well,

Anatomically you have to consider what is measuring where. Naturally, measuring the Lead II would show a more appropriate view of the electrical conduction as a whole, however, when measuring BBB we always look to the V1 when viewing on a 5 lead ECG system. That being said, more defined atrial activity may be noted when monitoring in Lead I. As far as MCL, I'm not superfamiliar with monitoring in that lead. As I glance at a monitor right now, I note that V and MCL have extremely similar shape.

 

[mgr22]

Two words in your opening sentence that beg a response are "never" and "theory." I don't think it's appropriate to teach "never" monitoring in Lead II. Each lead has potential to tell you something about the heart. Why would you want to limit yourself? I think Lead II is as good a place to start as any. What you see or don't see there gives you prompts about how to use your monitor and your skills to continue your assessment. At the very least, you'll have clues about rhythm, rate and regularity.

 

[EMSrush]

Was this by chance a lecture by Mr. Page?

 

[18G]

Was this by chance a lecture by Mr. Page?

I have heard the same thing and it came from a Bob Page class.

 

[bigdogems]

Yes it was from one of his lectures. I'm not saying it isn't accurate but I would like to see some other place that backs it up. Advanced Cardiology book, EP book, ect

 

[EMSrush]

I don't see any reason why you can't try to email him from his website, and see what you get. I've heard he's pretty good about responding to inquiries, especially if you let him know that you attended one of his lectures and had a question or two...

 

[Melclin]

I just monitor in whatever lead has the clearest QRS so the f**king thing doesn't alarm.

This notion of a person being in VT without me knowing scares me a little. If you figure this out, do post the results.

 

[bigdogems]

I did email and got a response right away but was directed to his 12 lead book. Now it was put out by Brady so I would like to think there is plenty to back it up. I would like to see this info from another source however. I am by no means trying to take anything away from his lectures. They are completely outstanding and I have learned a ton from his other lectures. This one too, I just would like some more info than what is being put out there by just 1 person

 

[TomB]

It's not that lead II will look "normal" when the patient is in VT but it's possible that lead II will be isoelectric or the QRS complexes could appear to be narrow (as they often do in right bundle branch block because your eye is drawn to the tight R-wave and not the slurred S-wave) whereas lead V1 shows clear wide complexes. Of course it could happen the other way around, too. There's nothing wrong with lead II. It's a fine monitoring lead but no one lead is perfect, so it's good to monitor leads that look at the heart from different angles. When I was a cardiac monitoring technician in a critical care stepdown unit (back in the day) I would use leads II, V1 and V6 (derived leads from the Zymed EASI system).

 

[Dwindlin]

In the OR here the gas guys use II, V1, V5.

Their rational is II is most specific for P-waves, V1 is most specific for ventricular rhythms, and V5 most specific for ST changes.

I don't have any studies backing this up this is simply what was relayed to me by the anesthesiologists I rotated with.

 

[systemet]

In the OR here the gas guys use II, V1, V5.

Their rational is II is most specific for P-waves, V1 is most specific for ventricular rhythms, and V5 most specific for ST changes.

I don't have any studies backing this up this is simply what was relayed to me by the anesthesiologists I rotated with.

Not trying to come across as overly pedantic, but generally the term "specificity" is percentage of individuals with a exhibiting a specific sign / symptom / diagnostic finding have a disease / condition of interest.

e.g. >90% of patients with acute chest pain that have a 12-lead showing ST elevation are suffering from an acute MI. (for example, Trädgård et al.)

To make what might seem like a trivial point, you could perhaps say that lead II is most sensitive for P waves, i.e. if you are going to detect P waves, you're most likely to see them in lead II.

Whether V1 is most sensitive for ventricular rhythms is difficult to say, really. I think you need to look at the gestalt of the 12-lead, and even then it can be difficult to differentiate a lot of wide complex tachycardia. To say changes there are more specific than in other leads is difficult to say.

Obviously ST elevation in V5 is indicative of lateral wall infarction, but ST changes in V5 will be less apparent in infarctions affecting other regions of the myocardium.

I realise I'm probably coming across as a bit of a ****. This is probably one of my Sheldon Cooper moments.


Trägårdh E, Claesson M, Wagner GS, Zhou S, Pahlm O. Detection of acute myocardial infarction using the 12-lead ECG plus inverted leads versus the 16-lead ECG (with additional posterior and right-sided chest electrodes). Clin Physiol Funct Imaging. 2007 Nov;27(6):368-74. http://www.ncbi.nlm.nih.gov/pubmed/17944659

 

[Dwindlin]

Not trying to come across as overly pedantic, but generally the term "specificity" is percentage of individuals with a exhibiting a specific sign / symptom / diagnostic finding have a disease / condition of interest.

e.g. >90% of patients with acute chest pain that have a 12-lead showing ST elevation are suffering from an acute MI. (for example, Trädgård et al.)

To make what might seem like a trivial point, you could perhaps say that lead II is most sensitive for P waves, i.e. if you are going to detect P waves, you're most likely to see them in lead II.

Whether V1 is most sensitive for ventricular rhythms is difficult to say, really. I think you need to look at the gestalt of the 12-lead, and even then it can be difficult to differentiate a lot of wide complex tachycardia. To say changes there are more specific than in other leads is difficult to say.

Obviously ST elevation in V5 is indicative of lateral wall infarction, but ST changes in V5 will be less apparent in infarctions affecting other regions of the myocardium.

I realise I'm probably coming across as a bit of a ****. This is probably one of my Sheldon Cooper moments.


Trägårdh E, Claesson M, Wagner GS, Zhou S, Pahlm O. Detection of acute myocardial infarction using the 12-lead ECG plus inverted leads versus the 16-lead ECG (with additional posterior and right-sided chest electrodes). Clin Physiol Funct Imaging. 2007 Nov;27(6):368-74. http://www.ncbi.nlm.nih.gov/pubmed/17944659

I am well aware of what sensitivity and specificity are. Also we are not talking about capturing a full 12-lead, the discussion is about continuous monitoring. I am aware that V5 corresponds to part of the lateral wall. My point was that If you can only pick a few leads to monitor choosing V5 gives you the best shot at capturing evolving ischemia (article on detecting ischemia during anesthesia).

Same goes with the other two leads. You are most likely to pick up p-wave changes with II and QRS abnormalities with V1.

 

[systemet]

I am well aware of what sensitivity and specificity are. Also we are not talking about capturing a full 12-lead, the discussion is about continuous monitoring. I am aware that V5 corresponds to part of the lateral wall. My point was that If you can only pick a few leads to monitor choosing V5 gives you the best shot at capturing evolving ischemia (article on detecting ischemia during anesthesia).

Cool. Great article, I stand corrected. Thanks for helping me learn something new. Sorry if I caused any offense.

(Here's a link / citation for one of the research articles cited in the review article Dwindlin linked, if anyone is interested).

London MJ, Hollenberg M, Wong MG, Levenson L, Tubau JF, Browner W, Mangano DT.Intraoperative myocardial ischemia: localization by continuous 12-lead electrocardiography.Anesthesiology. 1988 Aug;69(2):232-41. http://www.ncbi.nlm.nih.gov/pubmed/3407971?dopt=Abstract

Same goes with the other two leads. You are most likely to pick up p-wave changes with II and QRS abnormalities with V1.

I agree with respect to lead II. I wonder if V1 really is the most sensitive or if it's just the one we default to as clinicians for discriminating between RBBB/LBBB/NSIVCD?

 

[Dwindlin]

No offense taken. I should have been more clear in my original post.

There are some articles on best lead for viewing the QRS. I'm at work at the moment and don't have access to the site other than my phone so I will post them later.

Essentially the articles recommend V1 or V6 with V1 slightly out edging V6.

 

[Dwindlin]

Here is a link to a circulation article that discusses lead choice and placement. Link.

Long article. You can jump down to "Cardiac Monitoring Lead Systems" for the relevant portion.

 

[MSDeltaFlt]

Google "scholarly articles for monitoring V1 for morphology".

As far as "narrow complex tach", odds are it won't be V Rachel if you do a properly lead placed 12 lead and assess all 12 leads. Because it will more than likely be an aberrant conduction which is not ventricular at all. MCL1, MCL6, & even MCL4R can be used in monitors that do not have 12 capabilities. However, that monitor must be able to "assess", as in have an assessment function. Or it will be inaccurate. Why use these leads? Because Lead II has an accuracy rate of 34% in other words it is inaccurate 66% of the time. Though adequate for monitoring, it is pathetic for assessing.

 

[DV_EMT]

When I was a cardiac monitoring technician in a critical care stepdown unit (back in the day) I would use leads II, V1 and V6 (derived leads from the Zymed EASI system).

EASI.... making 12 leads possible from only 5....... (and when a stupid medical resident doesnt want to order a 12 lead with new onset chestpain and ECG changes)

 

[DV_EMT]

I just monitor in whatever lead has the clearest QRS so the f**king thing doesn't alarm.

AMEN to that! :beerchug:

 

[VFlutter]

EASI.... making 12 leads possible from only 5....... (and when a stupid medical resident doesnt want to order a 12 lead with new onset chestpain and ECG changes)

I work as a Monitor Tech and we do 5 lead Telemetry and we never use the EASI lead placement, its more hassle then its worth.