THE CLINICAL CONNECTION

GE Healthcare THE CLINICAL CONNECTION Training Choices. Anytime. Anywhere. Dash Series V5 Basic Bedside Monitoring Mentor Applications Class Workbook (Full Hemodynamics) PN:0304-CS-BUDFH Rev. A 2018408-009

Contents Table of Contents a c More Menu Options Program Description/Objectives and Schedule d Skin Prep and Lead Placement 6 Admit Menu 7 Equipment Overview Dash 3000 1 Dash 4000 1 CIC Pro 1 Laser Printer 1 PRN-50 Printer 1 Remote 1 Basic Use of the Monitor Direct Action Buttons Dash 4000 2 3 Trim Knob Control 2 3 More Menus 4 5 Adult ICU Rover Admit Menu 8 Adult ICU Combo 9 Adult ICU Rover/Combo Admit Menu 10 Alarm Control Alarm Levels 11 Silence Alarm 12 Alarm Volume 12 Alarm History 12 Display Off/Alarm Pause 13 All Limits 14 Arrhythmia Alarm Levels 14 Parameter Alarm Levels 14 Alarm Volume 14 Alarm Help 14 Display Off/Alarm Pause 14 Clear Alarms 14 Alarm History 14 GE Medical Systems Information Technologies, Inc. A General Electric Company going to market as GE Healthcare. a

Contents More Menu Options View Other Patient 15 View Alarm 15 View On Alarm Options 15 Select A Bed To View 15 Select Another Care Unit 15 Graph Viewed Bed 15 Auto View On Alarm 16 EK Pro / ECG EK Pro Algorithms 19 23 Display Leads 24 ECG Size 24 Detect Pace 24 ECG Limits 24 View All ECG 24 Clear V 2 through V 6 Fail 25 Arrhythmia Levels 25 More Menu Options Patient Data 17 Alarm History 17 Vital Signs 17 Graphic Trends 17 Cardiac Calcs 17 Pulmonary Calcs 17 Dose Calcs 17 CRG Trends 17 Lab Data 17 Monitor Setup 18 Relearn 25 ST Analysis 25 ECG Filter 25 12 Lead ECG Analysis 25 LD Analysis 25 1More ECG 25 Positioning of Electrodes 26 (10 Leadwire Configuration) 12 Lead Analysis 26 Obtain 12 Lead on a Patient 26 Print Multiple Copies of 12 Leads 26 12 Lead ECG Analysis Windows 27 Waveforms On/Off 18 Display 18 Color 18 Parameters On/Off 18 Graph Setup 18 b

NBP SPO 2 Contents NBP 28 NBP Go/Stop 29 NBP Auto 29 NBP Stat 29 Review NBP 29 NBP Limits 29 Cuff Size 29 Clear NBP Reading 29 Initial Inflation Pressure 29 Patient Prep for SPO 2 32 Signal Strength Indicators 33 Quality of SPO 2 Waveform 33 Stability of SPO 2 Value 33 Size 34 Rate 34 Rate Volume 34 SPO 2 Limits 34 Persistent SPO 2 34 Masimo SET Menu 35 Respiration Respiration 30 Invasive Pressures 36 38 Lead 31 Relearn Respiration 31 PA Insertion / Wedge 39 41 Sensitivity 31 Respiration Limits 31 Cardiac Output 42 44 Auto Size 31 Manual Size 31 Cardiac Artifact Alarm 31 Speed 31 References Learning Evaluation Facility Skills Checklist Verification of Objectives Program and Trainer Evaluation aa bb dd ee ff gg hh c

Basic Bedside Monitoring Dash 3000/4000 Series (V5) Basic Bedside Monitoring Mentor Applications Class (Dash Series V5 Full Hemodynamics) Program Description The Basic Bedside Monitoring Class with full hemodynamic parameters is a two hour program approved for AACN Certified Corporation 2.0 Contact Hours. This program is designed to provide the participant with an introduction to the basic operation for non-invasive parameters and full hemodynamic parameters on the GE bedside monitor. Program Objectives The objective of this program is to familiarize the Bedside Nurse with the operations of the GE Patient Monitoring System. Program Schedule 35 Minutes Overview and Objectives of Bedside Monitors. 10 Minutes Pacemaker Troubleshooting and 12-Lead Option. 15 Minutes Alarm Overview and Customization. 10 Minutes More Menus Options. 15 Minutes Arterial Line Menu and Features. 5 Minutes PA Wedge and Insertion. 10 Minutes Cardiac Output and Calculations. 5 Minutes Transport Procedure. 15 Minutes CIC Overview and Operation. Participant Learning Objectives At the end of this program, the participant will be able to: Demonstrate the admission and discharge of a patient. Demonstrate the knowledge and skills for basic operation of the bedside monitor. Show a basic understanding of alarm levels and customization appropriate to patient needs. Access each parameter box and perform operations specific to that parameter. Perform transport procedures (if applicable). Demonstrate knowledge and skills of the Clinical Information Center (if applicable). Demonstrate basic knowledge of applicable invasive parameters: Arterial Line. PA Wedge. Cardiac Output. Cardiac Calculations. d

Equipment Overview Dash 3000 Dash 4000 CIC Pro Laser Printer PRN-50 Printer Remote (optional) Dash 3000 Dash 4000 CIC Pro Remote PRN-50 Printer Printer 1

Basic Use of the Monitor Direct Action Buttons Use the direct action buttons as Quick Keys to monitor functions. The ZERO ALL button is to zero invasive lines open to air. The Silence button also serves as a Quick Admit key when the monitor is in the discharged mode. NOTE: All alarms are OFF until the monitor is in the admit mode. Trim Knob Control Rotate the Trim Knob in either direction to highlight a menu or select a parameter. Push the center of the knob to select the option. Dash 4000 Front Panel Buttons Power On/Off Graph Go/Stop NBP Go/Stop Zero All Silence Alarms / Admit Trim Knob 2

Basic Use of the Monitor Dash 3000 Front Panel Buttons Power On/Off Graph Go/Stop NBP Go/Stop Zero All Trim Knob Silence Alarms / Admit Invasive Pressure (Red) SPO2 (Blue) Temperature / Cardiac Output (Brown) NBP (Black) End Tidal CO 2 (Yellow) ECG (Green) Dash Monitor Side Ports 3

Basic Use of the Monitor Time and Date Monitor Default Name Care Unit and Bed Number Patient Name Parameter Waveforms More Menus Battery Capacity Guages More Menus The screen shows all monitored parameters and waveforms. The Main Menu has one menu option, More Menus, in the lower left corner of the screen. From the Main Menu, a parameter menu is accessed by selecting the appropriate parameter label, or other menus (not related to a specific parameter) can be accessed by selecting the More Menus option. 4

Basic Use of the Monitor Alarm Control: Displays a menu to view and modify alarms. View Other Patients: Displays a menu to select another bedside monitor on the network to view at this monitor. Patient Data: Displays a menu to view patient data; Alarm History, Vital Sign History, Graphic Trends, and enter various calculation programs. Monitor Setup: Displays a menu which allows the monitor to be configured to suit patient needs. Admit Menu: Displays a menu to enter patient demographic information and admit or discharge the patient. Battery Status: Displays a menu and information window which provides current battery status information. Main Menu: Takes the screen back to the Main Menu after adjusting options or viewing stored information. 5

Admission / Discharge The accuracy of ECG data displayed on the monitor is a direct result of the quality of the signal received at the electrode on a patient s skin. The following skin preparation guidelines are recommended: Skin Prep and Lead Placement Clip or shave hair from application sites. Gently rub area with gauze pad to remove dead skin cells. Cleanse site with alcohol or mild soap and water. Dry skin completely. Apply electrodes according to manufacturers recommendations. 3 Lead Placement 5 Lead Placement Front Leads AHA Level V1 V2 V3 V4 V5 V6 LA RA LL RL Standard Electrode Placement Fourth intercostal space at the right sternal border; right chest. Fourth intercostal space at the left sternal border; left chest. Midway, between locations V2 and V4; left chest. Mid-clavicular line in the fifth intercostal space; left chest. Anterior axillary line on the same horizontal level as V4; left chest. Mid-axillary line on the same horizontal level as V4 & V5; left chest. Below left clavicle. Below right clavicle. Flat, non-muscular surface on lower left edge of rib cage. Flat, non-muscular surface on lower right edge of rib cage. 6

Admission / Discharge Information Menu Standard Admit Menu Admit Menu Admitting a patient to the monitor is essential. All audible alarms are off and there are no alarm graphs or alarm history, and the patient will not be displayed at the CIC until the monitor is in the admit mode. To admit the patient and activate alarms, press the Silence Alarm/ Admit key. To admit the patient and activate alarms, press the Silence Alarm/ Admit key. To enter patient demographics at the bedside, select More Menus, and then the Admit Menu, then Change Admit Info. Name, Patient ID, Sex, Age, etc. are entered here. NOTE: If the monitor is connected to a CIC, the Name and ID Number may be entered from the CIC instead of the bedside. All other information must be admitted at the bedside monitor. 7 Change Admit Info: Opens an information window with menu options to enter/change patient information. Request Admit Info: Used to request patient information from a server with an interface to hospital information system. Recall Default: Opens a popup menu that allows recalling multiple monitor defaults. Admit Help: Opens an information window with admit help information for the monitor application being used. Admit Patient: A direct action menu option which admits the patient to the monitor. Units of Measure: Opens a popup menu that allows changing the units of measure for height and weight.

Admission / Discharge Adult ICU Rover Admit Menu Rover This application allows the monitor to be moved or roved to the patient s bedside. It has only hardwire capability and does not accommodate telemetry. To Admit a Patient Connect to AC power. Connect the Network cable. NOTE: This step is not required when using wireless Dash monitors. It is required for all other Dash monitors. Push the Power button to activate the display. Select More Menus. Select Admit Menu. Select Unit Name. From the information window, move cursor in front of the desired unit. Select Bed Set Number. From the information window, move cursor in front of the desired bed number. Select Admit Patient. NOTE: If the Unit Name or Bed Number windows do not appear, check that the network cable is connected (if applicable). To Discharge a Patient Remove all ECG leads from the patient. Select More Menus Select Admit Menu Select Discharge Patient Turn the Trim Knob to move the cursor in front of Discharge and press to select. Push the Power button to turn the display off. Store the monitor with AC power cord plugged in and the display off. NOTE: It is recommended to leave the network cable plugged in and the Dash display on for two minutes following discharge. 8

Admission / Discharge Adult ICU Combo Admit Menu Combo This application uses a monitor mounted in a room, but the ECG data can be acquired from either a hardwire cable from the monitor or a telemetry transmitter/transceiver. To Admit a Patient to Hardwire Select More Menus. Select Admit Menu. Select Admit Patient. To Change the ECG Source from hardwire to telemetry. Select More Menus. Select Admit Menu. Select ECG Source. Turn the Trim Knob to move the cursor in front of the desired telemetry transmitter/transceiver number or Monitor (Discharge Telem) for hardwire capability from the information window and press to select. NOTE: If the Telemetry transmitter/transceiver is being used for the ECG signal, the TTX number will appear in the ECG parameter box. To Discharge a Patient: Remove all ECG leads from the patient. Select More Menus. Select Admit Menu. Select Discharge Patient. Turn the Trim Knob to move the cursor in front of the desired discharge option and press to select. Return: Exit to Main Menu. Monitor: Discharges only the bedside monitor. Telemetry: Discharges patient from telemetry. Both: Discharges both the monitor and telemetry. NOTE: When discharging only the bedside monitor, all stored vital sign data will be deleted. The only data which will remain available will be HR, ST, PVC, and Alarm Histories. 9

Admission / Discharge Adult ICU Rover/Combo Admit Menu Rover-Combo This application combines the mobility feature of Rover monitoring with the telemetry capabilities of combo monitoring. To Admit a Patient Connect to AC power. Connect the Network cable. NOTE: This step is not required when using wireless Dash monitors. It is required for all other Dash monitors. Push the Power button to activate the display. Select More Menus. Select Admit Menu. Select Unit Name. From the information window, move cursor in front of the desired unit. Select Set Bed Number. From the information window, move cursor in front of the desired bed number. Select ECG Source. From the information window, move cursor in front of the desired transmitter/transceiver or monitor (hardwire) and press to select. NOTE: If the Unit Name, Bed Number or ECG Source windows do not appear, check that the network cable is connected. Select Admit Patient. To Discharge a Patient: Remove all ECG leads from the patient. Select More Menus. Select Admit Menu. Select Discharge Patient. Turn the Trim Knob to move the cursor in front of the desired discharge option and press to select: Return: Exit to Main Menu. Monitor: Discharges only the bedside monitor. Telemetry: Discharges patient from telemetry. Both: Discharges both the monitor and the telemetry. NOTE: When discharging only the bedside monitor, all stored vital sign data will be deleted. The only data which will remain available will be HR, ST, PVC, and Alarm Histories. NOTE: It is recommended to leave network cable plugged in and the Dash display on for two minutes following discharge (if applicable). Push the Power button to turn the display off. Store the monitor with AC power cord plugged in and the display off. 10

Alarm Control Key Icons System Status Alarms Key Icons Patient Status Alarms Alarm Control Admitting a patient to the monitor is essential. All audible alarms are off and there are no alarm graphs or alarm history. The alarms will not be activated until the patient is admitted. Within each classification, there are levels that correlate to the severity of the alarm-causing condition. The levels and how the monitor responds are described above: Alarm Levels The monitor s alarm structure is divided into two classifications: - Patient Status Alarms: Triggered by a patient condition which exceeds a parameter limit or by an arrhythmia condition. - System Status Alarms: Triggered by a mechanical or electrical problem (lead failure, artifact, arrhythmia suspend). 11

Alarm Control Silence Alarm Pressing the Silence Alarm key once will silence an active alarm for one minute. The message SILENCED will appear on the display. Any new alarm at an equal or greater alarm will sound. NOTE: If Crisis Alarm Breakthrough is set in defaults, all crisis alarms will break through Alarm Silence and Alarm Pause. Pressing the Silence Alarm key twice if an alarm is sounding will start an ALARM PAUSE. The length of pause will vary depending on the monitor s mode. The message ALARM PAUSE will appear on the display. NOTE: Alarm Pause Lengths: Adult ICU Mode: 5 minutes. Neonatal ICU Mode: 3 minutes. Operating Room Mode: 5 minutes, 15 minutes, Alarm Paused (permanent pause). Alarms will reactivate if the Silence Alarm key is pressed again. An Alarm Pause will immediately be activated if the Silence Alarm key is pushed in the absence of an alarm. Alarm Volume The alarm tone can be adjusted for the volume at the bedside. To adjust alarm tone volume: Select MORE MENUS. Select ALARM CONTROL. Select ALARM VOLUME. Turn the Trim Knob to the desired alarm tone and press to select. Select MAIN MENU to exit. NOTE: The alarm volume at the bedside monitor does not affect the alarm volume at the central station. NOTE: A minimum alarm volume can be set up in the monitor defaults. Clear Alarms Allows for any alarm information displayed in the alarm parameter window to be cleared from the display. To clear alarms: Select MORE MENUS. Select ALARM CONTROL. Select CLEAR ALARMS. Information from the alarm parameter window is removed. NOTE: Arrhythmia alarms are not deleted and can be found in the Alarm History. Alarm History See Patient Data tab. 12

Alarm Control Display Off/Alarm Pause This option allows the user to disconnect the patient from the monitor for an extended period of time. There are several alarm pause choices available: Display Off/Alarm Pause: This option turns off the bedside monitor and pauses the alarms at both the bedside and the central station for an indefinite period of time. Monitor Pause: This option turns off the bedside monitor, but allows alarm notification to remain active at the central station. To activate the Display Off/Alarm Pause feature: Select MORE MENUS. Select ALARM CONTROL. Select DISPLAY OFF/ALARM PAUSE. Move the cursor in front of the desired alarm pause choice and press to select. The display screen is now paused. Press the Power button on the monitor to reactivate the display and alarms. NOTE: Simply pressing the Display On/Off key will affect only the bedside monitor. A Lead Fail alarm will continually sound at the central station until the patient is reconnected to the monitor. 13

Alarm Control Alarm Control Menu Menu Options: All Limits brings up a popup window displaying all parameters and the current high and low alarm limits. Arrhythmia Alarm Levels displays a list of arrhythmia calls and their assigned alarm levels. Parameter Alarm Levels displays a list of all parameters and their assigned alarm levels. Alarm Volume adjusts the bedside alarm volume. Alarm Help displays an on-screen help window describing patient status and system status alarms. Display Off / Alarm Pause turns off the display and pauses alarms for this bedside monitor. Alarms at the central station may also be paused using this feature. Clear Alarms manually clears alarms displayed in the Alarm Window. Alarm History displays a list of stored arrhythmia alarms (Crisis, Warning, and Advisory Levels), and ST alarms and references. 14

View Other Patient View Other Patients gives you the ability to view data from another patient s monitor. There are three ways to view other patients: Select a bed to view. Select a bed in alarm. Automatically view a bed in alarm. (Future feature development requires purchased software option). 15 Menu Options: View Alarm: Select to display the patient data for the bed in alarm. View On Alarm Options: Displays a new menu that allows the selection of the View On Alarm options ON, OFF, or AUTO. Select A Bed To View: Open an information window from which to select a bed to view. Select Another Care Unit: Open an information window from which to select another care unit. This affects the list viewed in SELECT A BED TO VIEW. Graph Viewed Bed: Start a 20-second graph of the viewed patient data.

View Other Patient Auto View On Alarm (Future feature development requires purchased software option). To set up AVOA XM at the host monitor: Select MORE MENUS. Select VIEW OTHER PATIENTS. Select VIEW ON ALARM OPTIONS. The following choices will appear in the menu: VIEW OTHER BEDS ON ALARM allows turning the feature on or off at the host monitor. SEND AUTO VIEWS turns On/Off the host bed s broadcast of alarms to other beds on the network. ALERT TONE selects the audio alert at On, Off, or Repeating Tones. CONFIGURE AUTO VIEW ON ALARM allows you to select the care unit and beds to view automatically on alarm. The clinician can manually select which level of alarm will sound. (Crisis, Warning, etc.) 16 CURRENT CONFIGURATIONS displays the current AVOA settings for the host monitor which beds are selected to view on alarm and at which alarm levels. When viewing an alarm bed: MAIN MENU closes the split patient view and returns to the main display. RETURN closes the split patient view and returns to the VIEW OTHER PATIENTS menu. GRAPH 20 SEC starts a 20-second graph strip of the viewed patient data. SILENCE silences the viewed alarm bed for 60 seconds. LAST EVENT retrieves the last arrhythmia event from the viewed alarm bed. Select OK to return to VIEW OTHER PATIENTS menu. VITAL SIGNS displays the vital signs for the alarming bed. GRAPHIC TRENDS displays the graphic trends for the viewed alarm bed.

Patient Data Patient Data Alarm History, the same menu found under Alarm Control, lists stored arrhythmia and ST alarms. The monitor stores up to 36 arrhythmia alarms and 10 ST alarms or references. Vital Signs brings up a popup window displaying vital sign data. The monitor stores up to 24 hours of vital sign data. Graphic Trends displays up to three parameters of data in graphic form over a specified period of time. Cardiac Calcs allows access to the cardiac calculations program, if performing cardiac output measurements with a device other than the monitor (CCO, etc.), or the clinician wishes to review stored calculations. The monitor will store up to 20 cardiac calculations. 17 Pulmonary Calcs allows manual data entry from arterial blood gases and monitored ventilator parameters to derive pulmonary calculations. The monitor will store up to 10 pulmonary calculations. Dose Calcs provides an accurate and safe method of determining drug dosage as well as printable titration table. Up to four calculations can be stored. CRG Trends is used to view high resolution CRG Trends. (Feature requires a purchased software option). Lab Data is used to access laboratory data from a hospital lab information system. (Feature requires Lab Access Server).

Monitor Setup Monitor Setup Waveforms On/Off reassigns waveform positions on the display and turns waveforms On and Off. Display chooses the display mode, which puts waveforms on a full or individual scale, selects three or six waveform parameters to display or CRG Full or Individual. Color: Choose a color configuration. Parameters On/Off: Clear unneeded parameter windows from the display and turn them back on again when needed. NOTE: The ECG parameter can be turned off. When the ECG parameter is turned off, the SPO 2 parameter is the primary parameter for monitoring the patient. Graph Setup: Select waveforms to be graphed, graph speed, and where the graph will be printed. Monitor Defaults: Configure alarms, set alarm limits, and establish display defaults to be recalled whenever a discharge is performed. Brightness: Control how bright the display is. Learn The Monitor: Display information windows containing basic instructions on operating the monitor. Software Configuration: Display the monitor s software configuration. Revision and ID: Display software revisions and hardware ID s. Service Mode: Access a service mode (for qualified service personnel). 18

EK Pro Simultaneous multi-lead analysis is performed on leads I, II, III, and the V lead (with 5-lead set). This decreases false alarms caused by artifact and increases the accuracy of arrhythmia calls. ECG The following are examples of each arrhythmia the system calls. They are related to our most current level of software. Please consult your Operators Manual for the arrhythmia criteria relating to the level of software currently in the monitor. NOTE: Artifact may still occur due to patient movement, dry electrodes or inadequate skin prep. Artifact Message Alarm is displayed when artifact occurs on the ECG. Full arrhythmia processing is suspended. Lethal arrhythmia is still active, but its accuracy may be hindered by the artifact. Arrhythmia Suspend message will be displayed and a system warning alarm will sound if the artifact lasts for 20 of the last 30 seconds of ECG. At this point it is essential to troubleshoot the source of artifact as no arrhythmia processing is possible at this time. ACC VENT Adult: Accelerated ventricular occurs when six or more ventricular beats are detected with an average heart rate for the ventricular beat between 50 and 100 beats-per-minute. 0 2 Years: Between 60 and 160 beats-per-minute 3 10 Years: Between 60 and 140 beats-per-minute 11 13 Years: Between 60 and 130 beats-per-minute HR 0 ASYSTOLE Ventricular Asystole occurs whenever the displayed heart rate drops to zero. ATRIAL FIBRILLATION Characterized by random, chaotic, low-amplituded deflections of the supraventricular component of the ECG waveform, resulting in irregular timing of the QRS complexes and an absence of uniform P-waves preceding the QRS complex. 19

EGG BIGEMINY Bigeminy occurs when three or more bigeminal cycles (a ventricular beat followed by a non-ventricular beat) are detected. HR 44 BRADYCARDIA Bradycardia is the average of the most recent eight R-to-R intervals at a heart rate less than the set low heart rate limit. NOTE: Changing the low HR Limit will change the Brady Limit. HR 71 COUPLET Coupling occurs when two ventricular beats are detected and have non-ventricular beats before and after the couplet. The coupling interval between the PVCs must be less than 600 milliseconds. 20

ECG HR 87 IRREGULAR IRREGULAR This occurs when six consecutive normal R-to-R intervals vary by 100 milliseconds or more. PAUSE Pause occurs when a default time setting interval is exceeded without a QRS complex being detected. The default can range from 1 to 5 seconds at 1/2 second increments. The beat pause selection is adjusted in the ECG: MORE ECG menu. PVC Isolated premature ventricular complexes occur when a premature ventricular beat is detected and has non-ventricular beats before and after. R on T This occurs when a ventricular complex is detected within the repolarization period of a nonventricular beat. 21

ECG HR 148 TACHYCARDIA Tachycardia is four R-to-R intervals at a heart rate greater than the set high heart rate limit. NOTE: If a high heart rate limit is changed, the Tachy limit changes. TRIGEMINY Trigeminy occurs when three or more trigeminal cycles (a ventricular beat followed by two non-ventricular beats) are detected. HR 27 V BRADY Adult: Ventricular Bradycardia occurs when a run of three or more ventricular beats is detected with an average heart rate that is less than or equal to 50 beats-per-minute. 0 2 Years: Less than or equal to 60 and beats-per-minute 3 10 Years: Less than or equal to 60 and beats-per-minute 11 13 Years: Less than or equal to 60 and beats-per-minute 22

ECG VFib/VTac Ventricular fibrillation occurs when the ECG waveform indicates a chaotic ventricular rhythm. V TACH Adult: Ventricular Tachycardia occurs when a run of six or more ventricular beats is detected with an average heart rate greater than or equal to 100 beats-per-minute. 0 2 Years: Greater than or equal to 160 beats-per-minute 3 10 Years: Greater than or equal to 140 beats-per-minute 11 13 Years: Greater than or equal to 130 beats-per-minute VT > 2 Adult: Ventricular Tachycardia > 2 occurs when a run of ventricular beats is detected with a duration of less than six beats but longer than two beats and with an average heart rate that is greater than or equal to 100 beats-per-minute. 0 2 Years: Greater than or equal to 160 beats-per-minute 3 10 Years: Greater than or equal to 140 beats-per-minute 11 13 Years: Greater than or equal to 130 beats-per-minute 23

ECG Pace Detection Indicators QRS Indicator Heart Rate Heart Rate Alarm Limits PVC Count (Full Arrhythmia Only) ST Measurement Point ST Analysis Data ECG Parameter Box Display Leads changes the top displayed (primary) ECG lead. When monitoring in the single lead analysis mode, it is the only lead used for arrhythmia processing. ECG Size changes the size of all ECG waveforms displayed and graphed. Detect Pace turns pacemaker detection On and Off, and accesses Pace Help. 24 Pace 1 and Pace 2 modes use different algorithms for pacemaker artifact rejection. The Pace 2 mode is more conservative in recognizing paced QRS morphologies and is recommended for use whenever possible. (See Pacemaker Troubleshooting QRG). ECG Limits displays a new menu and information window to adjust heart rate and PVC alarm limits. View All ECG displays six leads of ECG.

ECG Clear V 2 through V 6 Fail clears the V 2 V 6 Fail message displayed on the screen when only using the 5-leadwire set of a 10-leadwire cable. Arrhythmia Levels turns arrhythmia processing On and Off. Full and Lethal are available with the Cardiac Software Package. Relearn learns a patient s new QRS pattern. This can be useful to correct arrhythmia calls and heart rate values, and to restore ST measurements. During relearning, an X replaces the heart rate value and the message Learning appears on the display. ST Analysis is performed on multiple leads, simultaneously. It identifies the ST segment of the QRS as beginning at the J-Point and ending predetermined milliseconds following the J-Point. The menu options allow turning ST analysis On and Off, printing ST trends and complexes, storing new references, adjusting ST alarm limits, identifying the V lead, and adjusting the ST point. NOTE: Storing new references is for visual reference only and does not affect the ST processing. ECG Filter selects levels of filtering for the ECG waveform data on the display and graph. Filtering affects the ECG waveform only and does not affect ECG analysis and arrhythmia analysis. The moderate filter mode reduces high frequency interface, i.e., ESU. Moderate and maximum ECG filtering are not recommended for pacemaker patients. Maximum Filter alters the displayed ECG morphology. Do not rely on ECG morphology for diagnostic purposes when this filter is selected. 12 Lead ECG Analysis: Display 12 leads of ECG with special menu options for analyzing and printing. LD Analysis: Choose single-lead or multi-lead processing of ECG and arrhythmia. More ECG: Display a new menu to turn the QRS tone On/Off, adjust volume when on, specify the QRS width type, and adjust the beat pause interval. 25

12 Lead ECG Positioning of Electrodes 10 Leadwire Configuration For the most accurate serial comparison, use the same electrode configuration as used on prior analysis. Procedure Prior to 12 Lead 1. Place patient in supine position. 2. Correctly identify and place all 10 electrodes according to hospital protocol. 3. Select the ECG Parameter box. 4. Select 12 LEAD ANALYSIS Correctly enter all demographics in the ADMIT MENU to ensure proper identification and storage. 5. Select ADMIT INFO. 6. Select CHANGE ADMIT INFO and enter correct information: Last Name/First Name: Enter complete and proper name. Patient Identification Number: Determined by facility, i.e., medical record number, social security number. Correct Age: This impacts the analysis. Location and site: Utilized when sending 12 lead to the MUSE. Identifies the hospital and unit. This information is set in defaults. NOTE: Depending on facility policy, other fields may be required; i.e., Technician ID, Optional Field, Order Number. 7. Select RETURN 8. Select SAVE CHANGES Perform a 12 Lead 1. Select 12 LEAD ECG NOW. Message appears in upper left corner of monitor. PERFORMING ANALYSIS - PLEASE WAIT In 30 seconds, unconfirmed analysis report appears. Post 12 Lead It is recommended to assess the quality of the 12 lead before proceeding. Select one of the four options below: Front Leads 12 Lead ECG Electrode Placement V1 Fourth intercostal space at the right sternal border; right chest. V2 Fourth intercostal space at the left sternal border; left chest. V3 Midway, between locations V2 and V4; left chest. V4 Mid-clavicular line in the fifth intercostal space; left chest. V5 Anterior axillary line on the same horizontal level as V4; left chest. V6 Mid-axillary line on the same horizontal level as V4 & V5; left chest. LA Left deltoid or left wrist. RA Right deltoid or right wrist. LL Left thigh or left ankle. LA Right thigh or right ankle 1. Select TRANSMIT-PRINT. Prints a copy to the laser printer and sends a copy to the MUSE. 2. Select TRANSMIT. Sends a copy to the MUSE 3. Select PRINT. Prints a copy to the laser printer. 4. Select DELETE. Analysis is erased. To Print Multiple Copies of 12 Lead 1. Press the GRAPH GO/STOP button on the monitor prior to choosing one of the four options above. Each time the GRAPH GO/STOP button is pressed, a copy is sent to the laser printer. 26

12 Lead ECG Analysis in Progress Message 27

NBP Accuracy of NBP measurement depends on using the proper cuff size. It is essential to note the circumference of the limb and check the cuff for proper size using the range markings printed on the inside of the cuff (DINAMAP/Critikon). Inappropriate cuff selection or improper application will result in erroneous measurements. NBP Go/Stop Systolic Value NBP Parameter Window Diastolic Value NBP Auto Timer Limits and Units Time of Last Measurement and Cuff Size Mean Value 28

NBP NBP Go/Stop initiates a single NBP measurement without going into the NBP menu. It can also be used to stop a measurement already in progress. NBP Auto starts/stops the automatic mode selects a time interval. NBP Stat starts five minutes of continuous, sequential NBP measurements. (Not available in the Neonatal ICU mode). Review NBP reviews previous NBP measurements stored in vital signs. NBP Limits displays an information window and a new menu to adjust systolic, diastolic, and mean limits. Cuff Size is used to select the type of cuff being used, (adult, pediatric, neonatal), and adjusts the initial inflation pressure. Clear NBP Reading removes the current value from the NBP parameter window. Cleared value will not be stored in vital signs. Initial Inflation Pressure determines the specific target inflation pressure for the first NBP measurement. 29

Respiration Respiration Parameter Window Limits and Units Lead Monitored Breath Indicator Respiration Rate Respiration is detected by measuring thoracic impedance. When respiration are monitored, a small AC signal is applied through ECG Lead I or Lead II. This signal appears between the right arm and left arm electrodes, or right arm and left leg electrodes, depending on the selected ECG lead. The lead selected is dependant on whether a patient is a chest breather or an abdominal breather. 30

Lead changes the lead from which the respiration rate is derived. (Lead I or Lead II). Relearn Respiration initiates a monitor relearn of the patient s respiration system. Sensitivity increases or decreases the sensitivity setting. The lower the percentage, the greater the detection sensitivity. Respiration Limits displays a new menu and information window to adjust respiration rate and apnea alarm limits. Respiration Auto Size automatically sizes the respiration waveform to fit in a predetermined area on the screen. NOTE: Adjusting the displayed size does not change the sensitivity. Manual Size increases or decreases the size of the respiration waveform. Cardiac Artifact Alarm turns the artifact alarm on and off. The Cardiac Artifact Alarm alerts the clinician to the fact that the respiration rate is within 5% of the heart rate over 30 consecutive breaths. Speed: Change the sweep speed for the displayed respiration waveform. I II Chest Breather Abdominal Breather Inspiration Marker Expiration Marker Example of a Good Respiratory Waveform (Regular and Even) 31

SPO 2 Patient Preparation for SPO 2 Monitoring Choose the probe that is best suited to your patient needs: ear, finger, disposable, reusable, etc. Clean the surface of the probe before and after each patient use. Following the instructions provided with the probe, correctly position and attach the probe to your patient. When a Masimo sensor is repositioned at any time, disconnect the cable from the sensor before repositioning. Reconnect sensor to cable after proper patient preparation and placement. NOTE: Good clinical practice includes proper probe placement and maintenance of probe position on the finger to prevent false SPO 2 readings from ambient light interference. SPO 2 monitoring is a non-invasive technique used to measure the amount of oxygenated hemoglobin and pulse rate. This is done by measuring the pulse absorption of selected waveforms of light. The light generated in the probe passes through the tissue and is converted into an electrical signal by the photodetector in the probe. The monitor processes the electrical signal and displays a waveform and digital values for SPO 2 and pulse rate. The Dash 3000 and Dash 4000 (V5) monitors incorporate two different technology options for interpreting SPO 2 values: Nellcor Masimo Set NOTE: The type of SPO2 technology available is based on equipment purchased. 32

SPO 2 SPO 2 Parameter Window Signal Strength Indicators Limits and Units Pulse Rate Value SPO 2 Value In order for accurate SPO2 readings to be obtained by the monitor, it is important to correctly position the probe and verify the quality of the signal. There are three indications from the monitor that verify the quality of the data being displayed: Signal Strength Indicators Three asterisks = good signal strength Two asterisks = adequate signal strength One asterisk = poor signal strength The quality of the SPO 2 waveform: Noise or artifact may be due to poor probe placement or patient movement. Frequent or erratic changes in the value or waveform may indicate a poor signal. NOTE: When using Masimo technology, the waveform cannot be utilized as a quality indicator due to the fact that motion artifact is filtered. The stability of the SPO 2 value: Compare the heart rate in the SPO 2 parameter window with the heart rate in the ECG parameter window to confirm accuracy. NOTE: It is critical to observe all three indicators at the same time. Example of a Good SPO 2 Waveform 33

SPO 2 Both SPO 2 technologies include the following menu options: Size adjusts the size of the displayed SPO 2 waveform. The default size is 1x. Rate turns the displayed rate value on and off. Rate Volume turns on a tone that sounds each time a pulse is detected. This is a variable pitch tone which changes as the patient s saturation level changes. The volume of this tone can be adjusted. SPO 2 Limits displays a new menu and information window to adjust SPO 2 percent and rate (beats per minute) alarm limits. Persistent SPO 2 allows the SPO 2 parameter box to remain on the display after the SPO 2 cable has been disconnected. The parameter box displays PROBE OFF PATIENT when the cable is disconnected and an alarm sounds at both the monitor and the central station. This option may be turned on or off in the SPO 2 menu if enabled in defaults. 34

SPO 2 SPO 2 Masimo SET allows the sensitivity and averaging times to be adjusted. Sensitivity options include: - Normal for routine patient monitoring purposes. - Maximum for improved low perfusion performance and for faster tracking of SPO 2 changes. SPO 2 Masimo Parameter Window Averaging menu options determine how many seconds the collected SPO 2 information is averaged. Options for averaging times are 2, 4, 8, 10, 12, 14 or 16 seconds. Signal Strength Indicators Limits and Units Pulse Rate Value 35 SPO 2 Value

Invasive Pressures Systolic Value Diastolic Value Zero All ART Parameter Window Limits and Units Pulse Rate Value Mean Value Mean Value CVP Parameter Window Limits and Units Zero All is selected to zero multiple pressure transducers at one time: Level all transducers to the phlebostatic axis. Turn the venting stopcocks open to air, closed to patient. Press the ZERO ALL on the Dash series monitor. Verify that zero reference has been established. (Watch the parameter box for message) Close the venting stopcocks to air, open to patient. Each invasive pressure connector is labeled BP. For convenience, the monitor has a specific pressure name assigned to each BP connector. 36 These names can be changed during setup, so any pressure line can be plugged into any BP connector. Having the connectors named properly is important for proper waveform processing, since different algorithms are used for processing different pressure sites. A labeled pressure waveform is displayed when the patient s IBP cable is connected to the monitor. After a zero reference procedure is done, numerics are displayed in the pressure parameter window on the right side of the screen. The current systolic, diastolic, and mean values are displayed. Some pressures only display a mean value (CVP, ICP, etc.)

Invasive Pressures CVP Menu Scales changes the displayed scale size for this pressure. Cursor displays a movable cursor over the waveform. Clear Cursor removes the cursor from the waveform. Limits displays a new menu and information window to adjust alarm limits. Change Name displays a pop-up menu listing site name choices for this pressure connector. Zero sets the zero reference for this transducer only. IABP turns the intra aortic balloon pump feature on and off. Smart BP recognizes zeroing, fast flushing, and drawing blood and eliminates needless alarms associated with these procedures. Disconnect Alarm is a feature found in the ART and FEM pressure menus. If the mean pressure falls below 25 mmhg and the disconnect alarm is on, a warning alarm sounds and the message DISCONNECTED is displayed in the parameter window. Check the patient immediately in the event the catheter has been dislodged. Pulse Rate is found in the ART, FEM, and UAC pressure sites and displays a rate value in the parameter window. BP Filter sets the filter at 12 Hz or 40 Hz. 12 Hz is recommended for general monitoring. Calibrate Transducer adjusts transducer offset. Speed changes the sweep speed for this display. 37

Invasive Pressures ART Parameter Window with IABP IABP (Cardiopulmonary Software Package) Triggering GE Medical Systems Information Technologies recommends that the signal source used to trigger an intra aortic balloon pump should be the balloon pump itself. This ensures that the trigger signal is compatible with all modes of IABP. An extra set of ECG electrodes or an additional connection from the arterial line can be connected to the monitor s display for consolidated waveform viewing. The monitor measures arterial (femoral) pressure and displays both the pressure waveform and numeric pressure values. The IABP feature compensates for the irregularities in the pressure waveform caused by the IABP. Starting the IABP Program Select the IABP option from the pressure menu. When ON, the parameter label begins with an I (IART1). 38

PA Insert / Wedge PA Parameter Window with Inflate Balloon Message The PA Insertion/Wedge Display was designed to provide the clinician maximum visualization during central line insertion. PA Insertion: To adjust the display when the PA catheter is being inserted, select PA INSERT/WEDGE from the PA parameter box. This removes all BP waveforms from the display, except the PA, to optimize PA visualization. Numerics for all other waveforms are still displayed on the right side of the screen. PA Wedge: To perform a PA Wedge measurement, select the PA parameter box, select PA INSERT / WEDGE. 39 Auto Wedge: Click on the MODE option to change from Manual to Auto. This mode will allow performing a measurement without having to touch the monitor once the program is started. (Manual Mode requires additional steps at the monitor to complete the measurement). Once Auto Mode is active, a message appears in the PA parameter window: INFLATE BALLOON. Print Insertion: When PA Insert/Wedge is selected, choose GRAPH BP INVASIVE to print insertion.

PA Insert / Wedge Review Wedge Information Window As the program senses the catheter wedging, the prompt changes to WEDGE PROCESSING. Deflate the balloon once wedging is adequate (3 to 4 respiratory cycles), but no longer than 20 seconds. The prompt will change to WEDGE COMPLETE. A PA Wedge Review information window will automatically appear. It contains 20 seconds of compressed waveform data. Move Wedge Cursor repositions the cursor to change the wedge value. Press the Trim Knob control to confirm and store the new PA Wedge value. Print Wedge: Press GRAPH GO/ STOP to print the waveforms in the PA Wedge Review Window. Once a PA Wedge pressure is confirmed, it will be displayed along with the time of the measurement in the PA parameter box. From the PA menu, the clinician may continue on to the Cardiac Output program by selecting CARDIAC OUTPUT from the menu options. This will also store the PA Wedge pressure value into the Cardiac Calculations and Vital Signs. PA Parameter Window with PAW 40

Cardiac Output Cardiac Output Complete The Cardiac Output program measures cardiac output by use of a thermodilution catheter. A numeric value and a real-time cardiac output washout curve are displayed on the monitor. The monitor allows performing multiple measurements and delete those not wanted. The Cardiac Output program averages the trials and automatically enters the values in the cardiac calculation and vital signs windows. 41

Cardiac Output Cardiac Output Menu Cardiac Output Window Delete CO Trials deletes trials that are not acceptable. Remaining trials are averaged automatically. Cardiac Calcs: After trials are accepted, click here to enter the Cardiac Calculations program. Cardiac Output Now performs one measurement each time this option is selected. Used in the MANUAL mode. BT Limits displays a new window where limits can be set for blood temperature. Also, where units can be changed from Celsius to Fahrenheit. Print CO Curve prints a copy of the displayed washout curve. Auto Mode turns Auto Mode On and Off, (manual). AUTO MODE (recommended) allows performing measurements without having to touch the monitor after starting the program. Use PAW allows selection of whether the PAW, PAD, or LA are to be factored into the cardiac calculations. Catheter selects the type of catheter. Used in calculating the computation constant. Inject Temp selects injectate probe type: In-line (room temp), or bath (iced). Used in calculating the computation constant. Size selects the catheter French size. Used in calculating the computation constant. Inject Vol selects the injectate volume to be used. Used in calculating the computation constant. Computation Constant allows manual entry of a computation constant. Cardiac Output Help displays an information window with troubleshooting tips. 42

Cardiac Output Cardiac Output Procedure Check Catheter Settings: Review the catheter name, size, injectate temp and volume to ensure correct computation constant is calculated. Cardiac Output Trials: Make sure Auto Mode is on. Inject solution over four to five seconds at end expiration. Monitor will display INJECT WHEN READY message. The monitor will retain four injections. Deleting Cardiac Trials: Select to delete any displayed trials. The average CO will be recalculated automatically. (continued) 43

Cardiac Output (Cardiac Output Procedure continued) CO Parameter Windows Cardiac Calcs: Select to open Cardiac Calculations window. The average CO will appear in the list of calculations. If necessary, use the CHANGE VALUE option to edit any of the monitored parameter values. Save Calcs: Important! When satisfied with the set of cardiac calculations, select the SAVE CALC option. This stores the set of calculations for review. Review Calcs opens the Vital Signs program and displays all saved cardiac calculations data. 44

References Sweetwood H. (1997, June). ECG/Pacemakers, The clinical significance of low QRS voltage. Critical Care Nurse, 17(3), 73-78. Bridges, E. J. (2000, December). Monitoring pulmonary artery pressures: Just the facts. Critical Care Nurse, 20(6), 59-80. Bridges E. J., Middleton, R. (1997, June). Direct arterial vs. oscillometric monitoring of blood pressure: Stop comparing and pick one (A Decision-making algorithm). Critical Care Nurse, 17(3), 58-72. Alexander, R. W., Schlant, R.C., Fuster, V. (Eds.). (1998). Hurst s the heart: Arteries and veins. (Vol. 1, pp. 35-385). New York, NY: McGraw-Hill. Patton, J. A., Funk, M. (2001). Survey of use of ST-segment monitoring in patients with acute coronary syndrome. Am. J. Crit. Care, 10, 24-34. aa

Learning Evaluation 1. The monitor must be admitted in order to: a. Activate pacemaker detection. b. Begin acquisition of data. c. Display an ECG waveform at the bedside. d. Enable alarms and send information to CIC. 2. When the monitor is in Alarm Pause: a. All alarms are suspended for five minutes. b. All alarms are suspended for three minutes. c. All alarms are suspended indefinitely. d. All alarms are suspended but event storage continues. 3. Which one of the following is TRUE regarding the automatic mode for NBP readings: a. Changing the Auto time interval initiates an immediate cuff reading. b. Pressing the NBP GO/STOP button does not reset the automatic cycle. c. Monitoring Q five minute NBP for extended periods of time is recommended. d. Three consecutive error messages will turn off the Auto mode. 4. What is the correct anatomical position for the V1 electrode: a. Fourth intercostal space, right sternal border. b. Second intercostal space, mid-sternum. c. Third intercostal space, mid-sternum. d. Wherever you want to place it on the chest. 5. How much data does the monitor store: a. 24 hours of arrhythmia events and 24 hours of vital signs. b. 36 arrhythmia events and 24 hours of vital signs. c. 40 arrhythmia events and 28 hours of vital signs. d. Storage is programmed at the time of admission. 6. Which one of the following is TRUE regarding the Message Level Alarm: a. Causes arrhythmia alarm storage. b. Provides a visual message only. c. Requires a manual reset. d. Triggers an alarm graph. bb

Learning Evaluation 7.Which one of the following statements about the pacemaker detection mode is TRUE: a. Pacemaker detection is multi-lead, similar to arrhythmia analysis. b. The PACE 1 mode is most effective for dual-chamber pacemakers. c. The pacemaker mode should not be activated if the patient is not showing a paced rhythm. d. Select PACE 2 initially, since this mode is least likely to result in double-counting. 8. An effective alternative electrode placement for paced patients discussed in class is: a. Change the RA and LA lead positions. b. Move V1 to the V6 position. c. Move the RA lead below V1 lead, and the LL lead up directly across from V1 at the left sternal border. d. Move the RL lead above V1 lead, and the LL lead up directly across from V1 at the left sternal border. 9. Which menu contains Graph Setup: a. Alarm Control. b. ECG. c. Monitor Setup. d. Patient Data. 10. Which menu contains the bedside Alarm Volume control: a. ECG. b. Monitor Setup. c. Admit. d. Alarm Control. 11. The message Arrhythmia Suspend appears on the monitor when: a. One or more of the leads become disconnected from the patient. b. The silence alarm key is pushed more than one time. c. Noise on the ECG waveform lasts for 20 of the last 30 seconds. d. The alarm volume is turned off. 12. When monitoring ST segments, all of the following are true EXCEPT: a. ST segments are always initially measured from the isoelectric point of the ECG. b. When the ECG baseline is relearned, the ST baseline is also reset. c. ST limits for each area of the heart (ANT, INF, LAT) can be adjusted independently. d. Displayed ST complexes can be changed to more appropriately monitor a specific area of the heart at any time during monitoring. cc