# Stroke & Cardiac Monitoring



## VFlutter (May 27, 2012)

I work as a monitor tech and I have noticed that recently a lot of doctors have been placing TIA/Stroke patients on telemetry monitors for 24/48 hours on admission. Can some one explain to me what, if any, changes you would expect to see on a telemetry monitor if a patient was actively having a stroke? I have had one patient who started to become bradycardic with increasing global ST depression who turned out to be having a hemorrhagic stroke but besides that the majority of patients i have had who have strokes while on monitor do not show significant changes in their rate or rhythm.

However this may just be a result of the growing trend of physicians wanting all of their patients on a monitor regardless of diagnosis or cardiac history. I am not saying this is necessarily a bad idea but it does create a large increase in workload on an already stressed system. We currently have the ability to monitor ~100 patients (excluding ICU) with two techs meaning each of us is responsible for 50 patients.  Most days we do reach our capacity and then have to work with discharging and prioritizing patients. 

So do you think that cardiac monitoring is essential for stoke patients and where does that rank in comparison to the ACS, MI, PE, Chest pain, etc patients when resources are limited.


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## usalsfyre (May 27, 2012)

The same as all of those conditions. Occlusive stroke shows a predisposition to coagulopathy


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## Hunter (May 27, 2012)

ChaseZ33 said:


> I work as a monitor tech and I have noticed that recently a lot of doctors have been placing TIA/Stroke patients on telemetry monitors for 24/48 hours on admission. Can some one explain to me what, if any, changes you would expect to see on a telemetry monitor if a patient was actively having a stroke? I have had one patient who started to become bradycardic with increasing global ST depression who turned out to be having a hemorrhagic stroke but besides that the majority of patients i have had who have strokes while on monitor do not show significant changes in their rate or rhythm.
> 
> However this may just be a result of the growing trend of physicians wanting all of their patients on a monitor regardless of diagnosis or cardiac history. I am not saying this is necessarily a bad idea but it does create a large increase in workload on an already stressed system. We currently have the ability to monitor ~100 patients (excluding ICU) with two techs meaning each of us is responsible for 50 patients.  Most days we do reach our capacity and then have to work with discharging and prioritizing patients.
> 
> So do you think that cardiac monitoring is essential for stoke patients and where does that rank in comparison to the ACS, MI, PE, Chest pain, etc patients when resources are limited.



Stroke is either a blockage or rupture that same can cause a heart attack.


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## d_miracle36 (May 27, 2012)

I believe alot of it has to do with finding a cause of stroke if it is ischemic in nature and seeing if the patient may have occasional bouts of a-fib and such.


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## mycrofft (May 27, 2012)

Majority of CVA's are blockers not bleeders. Atrial fib predisposes to CVA and/or pulmonary embolus. (Not to say a brain insult can't cause an arrhythmia, I do not know about that. Watch out, Google!).  

CVA if progressing (bleeder or a missed bleeder after sugary or anticoag Rx)  can change resp/cardiac readings by direct irritation (blood irritates brain's matter), ischemia or mechanical compression of the brain stem. Perhaps a resp or cardiac trend and CO2/pH changes can alert them to subtle changes?

Are these pt's on "clot busters"?


EDIT:
article about atril fib, deep vein thrombosis and CVA:

http://stroke.ahajournals.org/content/22/6/760.short

Not finding brain lesion causing atrial fib. DOES work the other way around.


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## d_miracle36 (May 27, 2012)

mycrofft said:


> Majority of CVA's are blockers not bleeders. Atrial fib predisposes to CVA and/or pulmonary embolus. (Not to say a brain insult can't cause an arrhythmia, I do not know about that. Watch out, Google!).
> 
> CVA if progressing (bleeder or a missed bleeder after sugary or anticoag Rx)  can change resp/cardiac readings by direct irritation (blood irritates brain's matter), ischemia or mechanical compression of the brain stem. Perhaps a resp or cardiac trend and CO2/pH changes can alert them to subtle changes?
> 
> Not finding brain lesion causing atrial fib. DOES work the other way around.




I would be interested in finding out how a cva predisposes patient to arrythmias. I recently read about patients having a cryptogenic stroke meaning they have no known cause. Most of these patients are on monitors to try to find a cardiac origin. I understand that a bleed causes cardiac complications but not so much about a blockage causing arrythmias


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## mycrofft (May 27, 2012)

I have failed to find cardiac arrythmias caused by intracranial insult, other than brain stem affect (e.g., eventual shut down). I suppose respiratory issues from brain insult could lead to circulating O2 levels low enough to irritate at-risk myocardium, but nothing direct and likely.


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## Brandon O (May 27, 2012)

The _majority_ of major brain insults (trauma, medical, whatever) are associated with some kind of cardiac response and ECG changes. Often it's non-specific, but the classic change is an acute heart failure secondary to myocardial stunning. Some people think it's a catecholamine surge, and analogous effects are seen in cases like Takotsubo cardiomyopathy and perhaps Prinzmetal's (none of these are well understood, by the way, so it's mostly theorizing). They may need inotropes or other support, but otherwise the effects are usually transient.

The classic ECG change is deep, huge, bizarre T-wave inversions. Osborne waves are sometimes seen as well. Good example: http://lifeinthefastlane.com/wp-content/uploads/2011/12/SAH1.jpg

I just happen to recently come across this study too, which has some pertinent remarks http://heart.bmj.com/content/28/6/768.full.pdf


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## DPM (May 27, 2012)

They might be keeping an eye out for  Neurogenic T Waves

That's all I can really think of.


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## d_miracle36 (May 28, 2012)

DPM said:


> They might be keeping an eye out for  Neurogenic T Waves
> 
> That's all I can really think of.


In the case of increase icp that can occur. Can it happen with a ischemic cva? I know in the prehospital environment when we have a unresponsive patient that may be all we have to go on.


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## DPM (May 28, 2012)

d_miracle36 said:


> In the case of increase icp that can occur. Can it happen with a ischemic cva? I know in the prehospital environment when we have a unresponsive patient that may be all we have to go on.



Did you read the article? "Neurogenic T Waves Preceding Acute Ischemic Stroke"


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## mycrofft (May 28, 2012)

Thanks, now my leisure reading is cut out for me!


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