dynamic protocol (2)

8/3/2019 Dynamic Protocol (2)

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DYNAMIC PROTOCOLS

FOR E.C.G

BY

MINJU


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DEFINITION

: To induce chest pain or discomfort

under controlled conditions in thelaboratories, that can be done by

certain protocols .This is known as

dynamic protocols.


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PURPOSES

Using controlled and carefully supervised

exercise to increase myocardial oxygendemand .

To evaluate the coronary arteries ability to

meet the increased demand successfully. To determine the typical and atypical

chest pain.


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PRINCIPLES

Skeletal muscle function should be proper.

Blood vessels should be patent. Cardiac function should be normal.

Myocardial function should be good.

Coronary perfusion should be clear.


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TYPES OF DYNAMIC PROTOCOLS

. 24 hours monitoring E.C.G. or ambulatory E.C.G.

. Radio Telemetry.. Holter Monitoring.

. Masters Double step technique.

. Bicycle Ergometry.. Stress Test or Tread Mill Test (T.M.T.)


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24 Hours E.C.G. monitoring

We use 3 modified chest leads usually.

Neutral lead placed just below the clavicle. V1 or V2.

Apical.


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PROCEDURE

> Place the electrodes over the chest and

connect the patient to a transmitter.> Ask the patient to perform an activity.

> It will show variations in E.C.G. if there is any

demand-supply mismatch.

> It can perform in I.C.U. only.


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RADIO TELEMETRY

#. A Transmitter is connected to the patient

with modified chest leads.

#. Ask the patient to go for a brisk walk of a radiusof 2 kms.

#. Continuous communication and monitoring of the

patient that will enable to monitor the E.C.G. forany abnormalities.


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HOLTER MONITORING

A Holter monitor is connected to the patient .

Ask the patient to go home and allow him to

do his daily activities.

Patient should maintain a dairy of daily activities

related with time.


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Patient should come back to the hospital after 24

hours.

By correlating the patients activity and abnormal

complexes, helps in identifying coronary

insufficiency.


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MASTERS DOUBLE STEP

Ask the client to climb-up and down in a

two step and do it vigorously,so exertion

is done.

It will be monitored and able to evaluate the

demand-mismatch supply.


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Disadvantage

It is very uncommonly performed because client

can take his own time.


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BICYCLE ERGOMETRY

Ask the client to ride a stationary bicycle

and go on.When examiner increase the resistance for

peddling, as a result of that, the demand

of oxygen and heart work load also be increased.

If heart is able to meet the demand, the heart

function will be normal.


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STRESS TEST OR TREAD MILL TESTDEFINITION:

Disease of the heart frequently are best evaluatedduring an altered state of physiologic stress of

the cardiovascular system.

The most common method of creating that altered

cardiovascular state is an exercise stress test or

tread mill test.


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OBJECTIVES

For the evaluation of chest pain.

To assess the signs and symptoms of

coronary artery disease.


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To evaluate the physiologic response of post-MI.

To evaluate the post revascularisation patients to

exercise.

To evaluate functional capacity for the purpose ofexercise prescription .

INDICATIONS


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To evaluate exercise capacity for the purpose

of work classification (disability evaluation)

and risk stratification (prognosis).

To evaluate the efficacy of medical,surgical,or

pharmacological treatment. To evaluate the presence and severity

of arrhythmias.

The know the preoperative physiological status. To evaluate intermittent claudication.


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CONTRAINDICATIONS

There are 2 types.

1.Absolute contraindication.

2.Relative contraindication.


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A recent change in the resting electrocardiogram

suggesting infarction or other acute cardiac event.

Recent complicated myocardial infarction.

Unstable angina.

Uncontrolled ventricular arrhythmia.

ABSOLUTE


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Uncontrolled atrial arrhythmia that compromises

cardiac function.

Third-degree atrioventricular heart block.

Severe aortic stenosis.

Suspected or unknown Dissecting aneurysm.


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Acute or suspected myocarditis or pericarditis.

Thrombophlebitis or intracardiac thrombi.

Recent systemic or pulmonary embolus.

Acute infection.

Significant emotional distress(psychosis).


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RELATIVE

Resting diastolic B.P.> 115 mm of Hg or

Resting systolic B.P.> 200 mm of Hg.

Moderate valvular heart disease.

Known electrolyte abnormalities (Hypokalemia).


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Fixed rate pacemaker.

Frequent or complex ectopy.

Ventricular Aneursym.

Uncontrolled metabolic disease.

Neuromuscular, musculoskeletal or rheumatoid

disorders that exacerbated by exercise.

Advanced or complicated pregnancy.


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PRE-TEST PREPARATIONS

Take a complete medical history and physical

examination.

Provide a detailed verbal and written

instructions to withhold ingestion of food,alcohol

and caffeine or using tobacco within 3 hoursof testing.


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Patient should be well rested and avoid vigorous

activity the day of the rest.

Wear non-constrictive and comfortable clothing.

Wear rubber-soled, supportive shoes during

testing. Inform the client of the purposes and risks

of exercise testing and obtain a signed consent.


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Record the patients B.P. and pulse.

Record standard 12 lead resting E.C.G.

Obtain a drug history of the patient.


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COMMON DRUGS AND IMPACT ON STRESS TEST

Drug Heart Rate B.P. E.C.G.

Betablockers

Ca channel

blockers

Digoxin

Rest :

Exercise:

Rest :

Exercise:

No change

Rest :Exercise:

Rest :

Exercise:

Rest :

Exercise:

signs ofischemia

signs of

ischemia

signs of

ischemia


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PROCEDURE

There are 3 phases.

1. Preparatory phase.

2. Performance phase.

3. Post exercise recovery period.


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1.PREPARATORY PHASE

Proper skin preparation.

Careful placing of electrodes in proper locationwith tape or a belt.

Examiner must take a baseline resting E.C.G.

before the test.


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Drape lead wires,cables and B.P. cuff to allowmaximum freedom of movement.

Record the patients pulse, B.P. before the test.

Emergency drugs and resuscitation equipments

should be kept ready.


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Target heart rate should be evaluated before test.

TARGET HEART RATE = 220 - AGE OF PATIENT.


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2. PERFORMANCE PHASE

Tread Mill is a motorized device that has an

adjustable conveyer belt.

It has a maximum speed of 1 to 10 miles/hr. The conveyer belt can be adjusted from a

horizontal position to 22% gradient.

It allows the client to walk or run on slopes at alldifferent stages.


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TREAD MILL TEST


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Total duration of T.M.T is 18 mins which

includes 6 stages of 3 mins.

Normal speed of T.M.T is 4 km/hr.

Maximum speed of T.M.T is 7 km/hr.

T.M.T starts with a speed of 2 km/hr.


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PROTOCOLS

: It means that a written plan specifying the

procedures to be followed in giving a particular test.


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There are 3 protocols.

1. Elstends protocol.

2. Balke & Naughton protocol.

3. Modified Bruse protocol.


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ELSTENDS PROTOCOL

Gradient remains constant

&

speed increase in every 3 mins.


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BALKE & NAUGHTON PROTOCOL

Speed remains constant

&

gradient increase in every 3 mins.


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MODIFIED BRUCE PROTOCOL

Both angle of inclination and speed

increase in every 3mins.


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Record the clients B.P, heart rate, rhythm stripand activity level at specified intervals.

Monitor the client for chest pain, arrhythmias, STsegment changes and changes in B.P.

Make frequent observation throughout testingfor any cardiac symptoms include extreme

dyspnea, claudication and vertigo.


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REASON FOR TERMINATION OF TEST

Chest pain.

Severe fatigue.

Greatly increased heart rate a(age related).

20-29 yrs. = 170 Bpm.

30-39 yrs. = 160 Bpm.

40-49 yrs. = 150 Bpm.

50-59 yrs. = 140 Bpm.

60-69 yrs. = 130 Bpm.


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Untoward signs and symptoms of myocardial

ischemia or heart failure.

Failure of systolic B.P. to rise or a drop in B.P.(below resting levels).

Sudden development of bradycardia.

Severe hypertension.

Severe dyspnea.


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ST segment depression (>2-4cm).

A sudden loss of co-ordination(cerebral ischemia).

Serious cardiac dysrhythmia.


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POST- EXERCISE RECOVERY PERIOD

After the procedure, assist the client to a chair or

bed for recovery.

Periodically monitor the clients B.P, heart rate

and rhythm strip for at least 15 mins. After

test completion or until the E.C.G. returnsto base line.


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Ask the patient to inform if he experience any

cardiovascular symptoms ( chest pain, shortness ofbreath or dizziness).

Restrict the patient from taking a hot shower for1 to 2 hrs. following the test.

Patient should be told that they may experience

fatigue and muscle soreness and to avoid heavy

exertion that day.


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DOBUTAMINE STRESS TEST

DEFINITION

:This is also known as chemical stress test which

includes Chemically exercising the heart with

controlled Infusion of dobutamine.

:This is indicated for the patients who is not able to

Perform physical stress test.


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dynamic protocol (2)

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