Need Help with a Situation/ST depression

[Babs0512]

This is more of a question from those with more cardiac experience than myself.

I had an OR patient in PACU last week, she had a hip pinning, no "big deal" surgery. She was 84 y/o.

When she came out to me, I received report and noted that she had huge ST depression. I ran a strip and showed it to the CRNA - whose reply was "Her rhythm as been the same thorought the case, don't worry about it. I also checked her BMP/CARD1 - her BUN/CREAT we slightly elevated, and her K+ was 3.1.

Her other Vs were stable. She herself denied CP, but then she was still sedated but rousable.

So I said to the CRNA, I've never heard of "Chronic ST depression, can you explain it to me?" He said "Maybe some other time" and walked away.

Not willing to let this go, I called one of the anesthesiologists in and told her of my concerns and showed her the patients preoperating EKG which showed "some ST abnormalities, abnormal EKG", and gave her the strip for comparison, NOTABLE difference.

The Anesthesiologist ordered at STAT EKG, I asked if she wanted a set of enzymes, she said no. The EKG came back, read by a cardiologist "ST abnormality greater than in preoperative EKG, still do not consider an acute MI"

I was frustrated to say the least. I thought we could at least draw serial enzymes and send her to Tele overnight instead of a med surge floor.

What should I have done differently? And can someone explain "chronic" ST depression. I'm ACLS certified, 8 years ER experience, and I've never heard of it.

Thanks

[suanna]

I've never seem "chronic" ST depression on a 12 lead. Often, with older people with chronic EKG changes- BBB, old MI... on Tele you can get false ST depression due to increasing the gain - but not on a 12 lead. Any ST change peri-op warrents serial enzymes. Stable VS may just mean there hasn't been enough damage(yet) to cause instability. Your docs are playing with fire if they ignore this.

[Virgo_RN, BSN, RN]

ST depression can be indicative of a lot of things, including ventricular hypertrophy, hypokalemia, or myocardial ischemia related to coronary artery disease. My guess would be that the cardiologist who interpreted the EKG probably did not see ST elevations in two adjacent leads, with reciprocal ST depression, which would indicate infarction. Plus if the patient already had ST depression and a known history of heart disease, increased ST depression in the perioperative setting may not be a completely unexpected finding.

[al7139, ASN, RN]

Hi,

I am a cardiac nurse on a Telemetry unit. You saw a pt with ST depression with a K of 3.1. The EKG changes indicate what the K showed. Remember that normal K levels are 3.5-5.0. This pt was hypokalemic, and even a little drop below the norm can show up as abnormal on an EKG. I don't know what else was going on with her (history, etc.), but even fasting for a surgery can cause the drop. Hypokalemia is caused by inadequate PO intake, some meds (diuretics, steroids, and some antibiotics or insulin), and excessive vomiting or diarrhea. In this case with the pts age and the required fasting for surgery, I would almost expect to see what you saw, including the elevated BUN/Creat (again from fasting). If the pt is otherwise asymptomatic (normal rather than low B/P and pulse), then all they need is to start eating and drinking asap after surgery. IF the K doesn't normalize after food and fluids, then I would worry. You were absolutely right to alert the docs to the abnormals you saw, but I would have flat out asked them to help you understand why they were not that concerned since you are learning, or asked one of you co workers to clarify.

Hope this helps.

Amy

[Babs0512]

Thanks to all who've replied. I feel like my badgering was the right thing to do, however, there were st depressions in 4 leads, can't remember which four - but anteriolateral ischema comes to mind.

I agree, they were playing with fire. I realize I didn't give you much to go on, I was tired when I wrote the question. The CRNA has been "teasing" me daily since then. When he brings a patient in, he'll say "Ekg's for everyone today, right Babs?" I always point out - go ahead and razz me, I WAS RIGHT - he finally conceded that point.

I guess I felt that I had gone as far as I could go, considering the woman continued to have no CP or SOB. Our on staff cardiologist, while confirming what I was seeing, and agreeing it was "more pronounced" than the preoperative EKG, still didn't feel it was acute. No where to go from there really. I made my suggestions for enzymes and tele, was told it "wasn't necessary".

The information you all gave me was appreciated. I was more or less just trying to see if I was on the right track with my thinking, and I now feel more assured that I was.

God Bless

[joeyzstj, LPN]

Another thing to consider is lead placement. A strip off of a monitor can show significant changes from a 12-Lead (Learned this one the hard way), however you stated that you got a post-op 12-Lead. Like NancyNurse stated, there are multiple reasons this happens. Lead variation (Leads placed in a different postion) will give you a different view then what was previously recorded. Watch your ECG techs sometime. I am willing to be that none of them place the leads in the same place twice or where they are actually meant to be. I prefer to do my own or at least watch them place the leads when possible. I have had techs place V-leads on the arms, Arm leads on the legs and leg leads in places people shouldnt have leads. Always consider K, Mag, Phos, Ca and other metabolic disturbances. These electrolytes will do all sorts of crazy things when they are low or high. You did what was responsible, so pat yourself on the back for that. Most of the people who have been around awhile get desensitized to events that commonly happen and this is probably why they didnt get too excited. It still doesnt mean you should ignore it.

[Babs0512]

Thank, but the lead placement was correct. I've learned to double check things over the years, especially before I call the physician in to "see what I found".