Help with inverted T-waves/reciprocol

DaFreak71 · Mar 31, 2006

Hey Again!!!
Gosh, I kinda remember my prev note was kinda breezy--like: Know the difference between 'inverted T' and 'depressed S-T segment' and worry about the latter, don't worry about the former. Was essentially what I said.
I apologize. You had a much better question than that and I should have recognized it.
Lets begin with the 'ischemia' business 'cause that's what we're here to prevent. It shows up in the SEGMENT. Glance at some of the 'Acute MI' illustrations in the websites recommended and you'll see that infarction and ischemia don't just 'flip' a T-wave, they show distress along the whole re-polarization part of the cardiac cycle, which is of course the S-T segment.
Now if--in the middle of your shift you notice that your Pt's T-Wave's have 'flipped'--you would obviously investigate (start by checking lead placement--which you should have peeked at in your initial assessment) and one of the possibilities is ischemia. So, depending on your index of suspicion--you would possibly get a 12lead and a set of enzymes as well as completely reassessed and maybe moved up a notch on your 'worrisome patient' list.
Now, one of the ways you'd verify that some sort of electrical 'event' was going on with the change in the T-Wave is by looking for the SAME T-Wave deflection on the 12lead that the monitor shows--in the lead that the monitor is set on. OK? You see I'm using the 12lead as a check on the bedside screen. Assume we find the same 'flip'--we look on the 12lead for OPPOSITE CHANGES in leads that are OPPOSITE PLACEMENT or POLARITY.
Those are the 'reciprocal' changes you asked about. (Of course, we are comparing this 12lead to the Pt's 'baseline' ECG!!!)
And by the way--GREAT WORK noticing the 'flipped T' and following up on it.
Now having said all that--I've never found much significance to 'flipped Ts'. I see some folks that have 'flipped' Ts on admission, don't admit to having heart disease, have normal lab and electolytes--but they don't fit the "Normal 12 Lead EKG". Othertimes, subtle things that show up on the monitor are covered by other assessments; you know the K level this morning is going to be OK because you know what the T-Wave looked like when it was high--and since the T Wave is normal tonight you're comfortable with the Potassium in the IV. That's how I have mostly viewed those subltle monitor changes--well worth their weight as warnings but not totally diagnostic on their own.
Thanx for following up. Hope I 'splained it better.
Papaw John

I'd like to shrink you down to the size of candy bar and carry you around in my shirt pocket. Please start writing text books. Soon. Like now would be good. I start nursing 2 in the Fall and I expect you to have it published by then. Thanks! :lol2:

Adri

chaosRN, ASN, RN · Apr 9, 2006

I'd like to shrink you down to the size of candy bar and carry you around in my shirt pocket. Please start writing text books. Adri

:yeahthat: papawjohn, you can explain things so easily.

To the OP: if you are worried about reciprocal changes, you can always get a RIGHT sided EKG. (make sure to write Right sided on it!!).

papawjohn · Apr 11, 2006

Hey Again Ever'body!!!

Gosh--these E-Mail referrals (someone has replied to a thread....) get me coming back here.

Was thinking about 'Reciprocal' changes--and had a little lite-bulb goes off over my head experience when I saw the suggestion about a Right-sided EKG ("AND WRITE 'RIGHT_SIDED' ON IT"). When I was new and trying to figure all this stuff out--looking at all the EKGs that found their way in front of me face--there was this really really weird one. I spent probably hours over a weekend trying to figure it out!! Finally, monday AM, the cardiolist makes rounds and I look over his shoulder as he's charting and mention: 'Gosh, this guy has the strangest EKG!!!' 'Yeah', the Dr says. 'He's got dextro-cardia. His heart's on the right side of his chest'.

ALL the waves on that one were 'reciprocal'. And altho I don't recall what it looked like--it was strange.

Papaw John

chaosRN, ASN, RN · Apr 11, 2006

I've seen dextro-cardia once. We had to put the leads on backwards. "White on Right" didn't aply - White went on left. and so forth. It was very strange. But very interesting!!