Biomed Certification Study Guide By Dave Harrington ELECTRICAL SAFETY

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1 ELECTRICAL SAFETY Eletril sfety testing is one of the most ommon proeures tht re one y Biome. Every ptient relte evie must e teste for eletril sfety efore it is initilly put into use n on some sis fter tht, it oul e t regulrly sheule intervls or just fter repirs. All eletril/eletroni evies hve urrent lekge rnging from few miro mps, (millionths of n mp) up to 0.50 mp. Vrious genies hve set urrent limits for eletril lekge urrents in meil evies. Not ll genies hve the sme limits. The Ntionl Fire Protetion Ageny, NFPA, AAMI, (Assoition for the Avnement of Meil Instrumenttion), or IEC, (Interntionl Eletril Commission) re some of the mny genies setting sfe urrent limits for eletrilly operte meil evies. In the lte 1960 s n erly 70 s there were severl pulitions stting tht up to 10,000 people per yer were eletroute in hospitls euse of efetive eletroni equipment tht ws pplie to ptients. In vrious stuies it hs een shown tht s little s 3 miro mps pplie iretly to portion of the hert uring ritil prt of the ri yle n use n rrthymi, (n norml et). If this norml et triggers itionl norml ets potentil for lethl rrthymi is present. Over the yers mny tehniques hve een evelope to limit the risk urrent tht ptient is expose to. They rnge from shortening the power ors; there is 1 miro mp of lekge per foot of or, to isoltion trnsformers so the evie ws not groune, ioes, hokes n ll sorts of other fixes. In the erly 1970 s it eme evient tht none of these fixes relly worke so the esigners strte to isolte the ptient from the evie. This ws one y using isoltion trnsformers, light emitting ioes or infr re links etween the ptient onnetions, (les), n the evie. These tehniques re still in use. There shoul e no non-isolte input evies left in moern hospitl s tht esign tehnique ws roppe y Almost everyone hs reeive n eletril shok t some point in their life. Working with 115 volts t 60 Hertz you n feel tingle t 1 milli-mp, (one thousnth of n mp). At 15 to 16 milli-mps you my not e le to let go of the ontt, t 50 milli-mps there is pin n musle ontrtion n from 100 m to 3 mps ventriulr firilltion n our. Aove the 3 mp level serious urns n eth n our. One enefit of working with DC voltge is tht firilltion is very unommon however urns n hppen quikly. Eletril sfety overs from the 3 miro mps up. Prtiulr onern is the rnge from 10 to 500 miro mps, whih n use mjor prolems to sik or injure ptient. As with most other hzrs the skin is the first line of efense for eletril hzrs. If there is iret onutive pth to the hert, rememer loo is onutive, ptient is t risk from ny evie tht my e onnet to them or one tht tht e touhe y re provier n the ptient t the sme time. Wht is onsiere the ptient viinity or re? There re s mny efinitions s there re people writing out eletril sfety in hospitls. A ommon efinition is ny evie tht is tthe to the ptient vi le wires or n e touhe y re giver while touhing the ptient is onsiere in the ptient viinity, this is generlly onsiere s 6 feet. Everything else is onsiere s generl hospitl equipment. Mny portle evies re rought into the ptient viinity n must e teste s ptient viinity n shoul not e onsiere s generl hospitl equipment. ELECTRICAL SAFETY TESTING There re vrious methos of performing eletril sfety tests, rnging from DVM with test lo to speilly esigne test instrument. The sfety nlyzer n either e n utomti or mnul unit. The utomti units re progrmme to perform ll the mesurements n inite test results tht re over the limits estlishe y the user. The mnul units require the person oing the testing to swith from 1

2 groune to ungroune, re the results n interrupt eh reing s to e inompline with the stnr eing use. Reverse polrity tests shoul not e one s they n mge equipment. GENERAL EQUIPMENT Equipment foun through out the hospitl or lini tht is not iretly onnete to ptients, it inlues oth meil n non-meil evies. In some filities non-meil evies re only teste when they re purhse n fter mjor repirs. In other filities they my e prt of the ontinuing PM testing progrm. There is not ntionl stnr for sfety testing on n ongoing sis fter the inoming inspetion. There re suggestions ut no leglly ining rules. COMPUTER or MICROPROCESSOR CONTROLLED DEVICES The mjority of these evies re in Clinil Lortory or Speilty Testing res of the hospitl. These units re only teste for eletril sfety efore instlltion n fter mjor repirs. If power is isonnete from this type of evie it my tke severl hours to get them k on line. This is why they re not teste for lekge uring the norml yle of inspetions. Groun heks shoul e one. PATIENT CONNECTED DEVICES, DIAGNOSTIC These evies mplify n proess signls etete in the oy y eletroes. The signls trvel over the le wires n ptient les to the evie where they re mplifie, proesse n isplye. The key points on this type of evie is tht it etets signl n hs wires etween the ptient n the evie. This tegory of equipment ontins suh evies s EKG, EEG, EMG reorers n ptient monitors. In the se of ptient monitors there my e severl plug in moules tht mke up the totl evie. A ptient monitor is teste s one evie s there is only one power or. The le wires of the vrious moules re teste to the power or groun. 1 Disonnet the evie from the wll power AND from ny other onnetion to other prouts or the entrl sttion. Perform the norml lening n visul inspetion steps inluing the power or n p plus ny missing or loose hrwre. Corret s neee. 2 Plug the evie into the sfety tester, n tth ptient les to the orret terminls of the sfety tester. If the sfety tester oes not hve le ontts onsult with your supervisor for how to test the le lekge. Test the groun resistne; perform the power off lekge tests, inluing les in the groune n ungroune moes. Return to the groune moe power the unit up, llow it to perform its selfignosti tests n perform the power on tests oth in the groune n ungroune moes. Any filures must e repire n oumente efore returning the evie to use. If the evie psses ll moules ontine in tht evie re eeme to hve psse. 3 If the evie hs power onitioner or isoltion trnsformer tthe, they shoul e teste s one evie. 4 When returning the evie to use reonnet ny t or interfe les tht were isonnete from the evie efore the testing strte. PATIENT CONNECTED DEVICES, THERAPEUTIC These evies eliver energy, fluis or gses to ptient. The elivery n lst for few milli-seons, s with efirilltor to yers for ventiltor or IV pump. In the se of n IV pump the fluis re ontine in non-onutive plsti so ny eletril ontt requires tht there e hole in the tuing. On ventiltors the tuing is non-onutive, s re most of the gs mixtures tht woul e ministere. 2

3 Beuse energy is elivere to the ptient it is not require to test the le isoltion while the unit is elivering tht energy, it oul lso e ngerous to test. The sme testing proeures s with ignosti evies is followe exept tht le lekge is only teste in the power off onition, with n without groun. Devies suh s ithermy units, ultrsoun therpy n stimultors fll into this tegory n my hve speil units for testing their outputs, hek with your supervisor on vilility of this speil test equipment. DEVICES in the PATIENT VICINITY These re generlly portle evies. The ommon efinition of Ptient Viinity is nything in n re tht linil person n touh n still mintins ontt with the ptient. This is generlly 5 to 6 feet roun the ptient. These evies o not hve iret ptient ontt, vi les or proes. On these evies the groun is very importnt s it reues or elimintes ny lekge on the hssis. Inlue in this tegory re portle X-Ry units, C-Arms, Dignosti Ultrsoun n other speilty testing evies. ELECTRICAL SAFETY ON PREMANENTLY WIRED EQUIPMENT or OVER 115 VOLTS These evies re generlly foun in linil lortories, entrl proessing n riology. If the evie is powere y 115 volts, it is teste for lekge t the time of instlltion. One it is instlle only groun testing is one uring the inspetion yle. For evies powere y over 115 volts there is no metho of performing true eletril lekge unless there is speil meter ville. In ition some evies will use 3-phse power. Groun testing eomes very importnt in these res. One tehnique tht is ommonly use is to selet one groun point in the re n mesure the groun resistne of ll expose surfes to tht point. The prolem with this metho is tht one le wire my hve to e s long s 20 feet to reh ll surfes in tht re. A vrition of this tehnique is to selet point, suh s the x-ry tle s the groun n mesure everything in the ptient viinity to tht groun point. With either tehnique the groun resistne shoul not exee 0.5 ohms. A key point to rememer in performing this type of groun resistne testing is to selet your strting point n oument it so tht the test n e repete. A smll of nil polish next to the groun point is one metho of oumenting where the groun point is. While it my e very iffiult to ontrol euse of outsie venors oing some of the repirs or PM s, ut the grouns shoul e verifie fter every mjor repir or venor provie PM. Personl Sfety While working in helthre filities you will e expose to numer of hzrs tht n ffet your helth. There re the norml exposures tht you hve in ny type of work, slips, flls, strins n fire. In helthre you n e expose to infetious gents, oth virl n teril, in oy fluis, oth y iret ontt or irorne, tissue n even smoke from lser surgery. These exposures n e limite y following the Universl Preutions proeures tht re in ple. Be wre of your surrounings t ll times, you o not nee to ewre or your surrounings. A goo rule to follow is WASH YOUR HANDS BEFORE AND AFTER ANY PATIENT CONTACT, EITHER DIRECTLY OR INDIRECTLY. Another goo rule is to look t n roun the oor leing into ptient s room or n re tht ptients re trete or where reserh is eing onute on tissue or oy fluis for wrnings. These wrning oul e s simple s olore imon shpe signs, ivie in qurters initing the hzrs present. It oul simply e the symol for iologil hzrs or rition. It oul lso inite tht the ptient in the room is uner preutions n my hve nother wor like reverse, respirtory, enteri. When you oserve suh sign o not enter the re without heking with the person in hrge. You my e require to put on protetive grments, gown, ht, gloves, msk n eye protetion efore entering the re. When the re touh s little s possile, e very reful s you move roun to voi hitting nything or using ny spills. No evies 3

4 or tthments, tuing et. shoul e remove from the re without first eing eontminte. If tools or test equipment re rought into restrite re they lso must e eontminte efore leving the re. Alwys follow the hospitl s poliies on Universl Preutions, plus ll other poliies n proeures relting to loo orne pthogens. In most helthre settings riotive mteril is uner lose supervision n presents little prolem to the Biome. Osionlly ptient with riotive implnt will e onnete to other evies tht my require your expertise. Agin follow the poste proeures on tht ptient s room oor. If in out sk questions. Never ssume tht it is sfe to enter. Review Questions 1 Aoring to ANSI stnrs wht is the high frequeny ut off for eletril lekge tests A 60 Hz B 100 Hz C 1,000 Hz D 10,000 Hz 2 Wht is the mximum resistne llowe etween the hssis of evie n groun pin of it s power or? A 0.5 Ω B 0.05Ώ C 0.01Ώ D 0.10Ώ 3 Wht is the urrent level onsier the let go point? A 15mA B 150mA C 1.5mA D 15µA 4 If portle evie is efetive n you nnot fix it right wy wht shoul you o? A Tpe sign Broken on the evie B Use the hospitl lok-out-tg out proeure C Remove it from the re D B n C 5 Wht re the U.S. power or olors for hot, neutrl n groun? Blk is Hot White is Neutrl Green is groun For interntionl power ors rown is hot, lue is neutrl n green/yellow is groun. When wiring plugs or out outlets the hot wire goes to the gol post. 6 The ltest US eletril oe requires Isolte Power Supplies in whih re? A The ICU B Clinil Ls C Operting rooms with no explosive gents llowe D None of the ove. 4

5 INTRODUCTION TO CARDIAC DEVICES In this setion oth the physiologil n eletroni spets of evies use to ignose, monitor or tret ri events re isusse. In most humns the hert is lote slightly to the left of the hest s miline. It is hollow musle tht is ivie into 4 prts. The first ivision is right to left. A thik musle lle the septum seprtes the sies of the hert. In the musles re unles of nerves tht onut impulses n tissue tht ts s pemker regulting the ontrtion of the hert. Eh hlf is further ivie into top n ottom setions. To further onfuse you there re 3 lyers of tissue tht mke up the hert. Eh hmer hs thin lining lle the enorium, the musle is lle the myorium n the s surrouning the hert is lle the peririum. The hert s pumping tion Bloo enters the relxe top hmers, (trium), of the hert from the superior n inferior ven v veins on the right n pulmonry vein for the left sie. This is lle the istole phse. When the hmer fills the SA, (sinotril), noe lote t the top of the right trium sens n impulse for the upper prts hert to strt to ontrt. The lower prt, ventriles, of the hert is relxe. On the right sie loo is fore through the Triuspi vlve into the right ventrile n on the left sie through the Mitrl vlve into the left ventrile. At this point the AV, (trioventriulr), noe, lote t the ottom of the right trium sens its signl own the Bunle of His n into the Purkinje fiers whih uses the ventriles to ontrt, this is lle the systole phse. The Triuspi n Mitrl vlves lose, preventing kflow into the trium, the Pulmonry n Aorti vlves open whih llows the loo from the right ventrile to move to the lungs n from the left ventrile to the rest of the oy. At the en of the ontrtion the ventriulr vlves lose n istole strts gin. This is lle norml sinus rhythm. Any ontrtion tht oes not follow this sequene is lle n rrhythmi. There is more informtion on the eletril tivity of the hert in the suggeste reings tht re prt of this moule. An etopi et ours when the SA noe is not funtioning or some other prt of the hert tissue ssumes the role s pemker. A multifol et is when oth the SA n AV noes re not properly working n ontrtions originte elsewhere in the hert. See the setion of the reings overing rrhythmis. Struturl fults in the hert n use the mixing of oxygente n non-oxygente loo. These efets re generlly holes in the septum tht i not lose fter irth. Mny ies will hve this type of efet n it self orrets fter few ys. Sometimes these holes n e pth using speil theters without the ptient going through n open hert proeure. Bsi hemoynmis in the hert The loo pressure in the right trium is the lowest of ll the hmers n is generlly the sme s the entrl venous pressure, (CVP), of the ptient, 2 to 10 mmhg is the ommon rnge, some soures sy 0 to 8 n this is men pressure. (Men pressure is of the highest pressure; think of it like n RMS Voltge). The right ventrile pressures uring ontrtion, (Systoli) rnges etween 15 n 30 n t en istoli, (t rest) it is the sme s the right trium. The left trium pressure rnges etween 5 n 12 mmhg ut is lmost never iretly mesure in linil setting. The left ventrile systoli pressures rnge etween 90 n 140 while the en istoli is 5 to 12 ll in mmhg. While not prt of the hert the pressure in the pulmonry rtery is of linil importne n is often monitore. Typil pressures in the pulmonry rtery re systoli 15 to 30, istoli 4 to 12 n men 9 to 16 gin ll in mmhg. Also mesure is the pulmonry pillry wege pressure, whih is men pressure n rnges from 1 to 10 mmhg. When monitoring the pulmonry rtery pressures it is possile to get 5

6 negtive loo pressure if the theter is not orretly ple, too fr own the rtery. Wht hppens s the ptient inspires they rete vuum t the theter tip, whih will show up s negtive pressure on some monitors. The key trouleshooting point on this is tht the negtive loo pressure only shows up t the sme frequeny tht the ptient is rething. Some monitors will not show negtive pressure ut will flt line t the zero pressure point. It is extremely rre tht the ompute reing (numeri isply of systoli, istoli n men pressures) will show negtive numer s they re verge over 3 to 5 ontrtions. The linil stff my omplin out low numers, ut the key is to look t the wveform for negtive going or ut off t the zero line on the sreen. If this is present the theter is too fr into the pulmonry rtery. Also rememer tht the pulmonry rtery ontins venous loo while the pulmonry vein hs oxygente or rteril loo. Prolems with vlves in the hert re generlly foun vi listening with stethosope or y the use of ultrsoun sns. If the vlves o not properly lose loo will regurgitte etween hmers. The ri vlves n thiken from vrious illnesses n some rugs, oth legl n otherwise n ffet them. The ommon term for thiken or nrrowing of vlves is stenosis. Sometimes the term prolspe is use for vlves not totlly losing properly. Tke time to review n lern the ommon meil terminology tht is inlue in the reing mteril ECG mplifiers An ECG mplifier, (EKG is Germn term tht is wiely use), is multi input mplifier, from 3 to 12 inputs. Eh input is for n eletroe ple on the skin to etet the eletril tivity of the hert. One of the eletroes will t s the signl groun referene point, (usully the right leg eletroe). A ptient monitor will use 3 or 5 eletroe inputs, while n ECG reorer will use 5, 10 or 12 inputs. Not mny units will use the 12 inputs s these extr 2 inputs re for eletroes ple on the ptient s k n re lle Frnk les. Terminology n get onfusing etween inputs, whih hve les, n t outputs, whih re lso, lle les. Also there re lim les n moifie lim les. Lim les hve the eletroes ple on the lims, typilly wrists n just ove the nkles, use on ECG reorers. Moifie lim les hve the eletroes ple on the shoulers n just ove the ptient s wist, use for monitoring in n ICU setting. To further onfuse you there re ugmente les, resistors re swithe into the inputs of 2 lims n the resulting voltge is mplifie. See figure 5 of Eletroriogrphy prt 2 in suggeste reings for this moule. Isoltion All inputs re isolte from the power supply of the mplifier y n isoltion trnsformer. This prevents ny power supply fult from putting voltge on the eletroes n potentilly giving n eletril shok to the ptient. Also eh input hs ioe, resistor or sprk gp iruit tht will short ny high voltge/high urrent pulses to groun so the mplifier is not mge. These pulses ome from efirilltors n eletrosurgil evies. The input impene of n ECG mplifier is sometimes liste s, ohms or CMRR. Typil numers re 100 MegOhm n 66 for the input impene. Swithes Amplifiers, oth those use for monitoring n reorers, hve swithing mehnism tht selets the wveform, (le) to e isplye. The swith my e rotry, pushutton or flt pnel. On some reorers there is n utomti utton, whih swithes the output through ll 5, 12 or 14 les epening upon the moe. On some units there is lirte position on the swith whih hs to e selete if the 1 mv signl is to e isplye. The 1 mv lirtion signl is use to onfirm the gin of the mplifier n is goo wy to o quik hek to see if the mplifier is properly funtioning. If the output shows the 1 mv signl the mplifier is working. This signl n lso e use to hek the ommunitions etween esie n entrl monitor in n ICU without onneting simultor to the mplifier. 6

7 Gin The stnr gin of n ECG mplifier is 1,000. The typil ECG input signl is 1mV, whih mens tht the output is 1 volt, whih trnsltes to 1M efetion on the sreen or hrt. Rememer tht this is iel n very few onitions in humn oy re iel. The mplifier my hve n utomti gin ontrol iruit to ssure tht 1 mv eomes 1CM. There my e swith where the gin n e selete. The swith will generlly hve settings of 0.25, (gin of 250), 0.5, (gin of 500), 1.0, (gin of 1,000 Stnr) 3.0, (gin of 3,000) n 5.0(gin of 5,000). As with ny mplifier sturtion n eome prolem, even t the lowest gin setting. This is ommon when the ptient is smll n with very strong hert, neontes n fll into this tegory s n thin thleti ults. A istorte wveform, usully with some peks or vlleys flt line, (lippe off). There lso n e voltge offset use y the eletroes ple on the ptient. This offset voltge n move the se line up or own n n use sturtion of the mplifier. To orret the prolem the eletroe with the high offset voltge hs to e lote n repositione or reple. Offset voltges normlly our ut generlly, with moern eletroes re miniml. Bsilly the eletroe is ting like ttery. Stinless steel eletroes hve high offset voltges n shoul e voie. Frequeny response ECG mplifiers hve two frequeny responses tht re seletle, monitor n ignosti. The monitor frequeny response is for long-term oservtion of the ptients ECG, s in n ICU setting, n is 0.5 to 35 Hz. This numer my vry etween mnufturers up to s high s 50 Hz. The monitor frequeny response is for oservtion not ignosing ptient s ri tivity. The ignosti frequeny response is from 0.1 to 100 Hz with noth filter to not pss frequenies of 50 n 60 Hz. The noth filter prevents noise from the power lines from eing mplifie n possily istorting the wveform. The ignosti frequeny response is use on reorers ut will sometimes e inlue in n ICU monitor. The upper numer in the frequeny response (35 or 100) is lso lle the 3 point of n mplifier. Simply the 3 point is the frequeny t whih the gin of n mplifier is reue y hlf. (In stereo system the 3 point is generlly 20,000 Hz). Eletroes Eletroes re ple on or in the ptient to etet the eletril voltges generte y the hert s it goes though ri yle. These eletroes rnge from short to long-term urtion in ontt with the ptient. Prolems n our when the wrong eletroes re use for the prtiulr pplition. The type of metl or onutive mteril use in n eletroe n ret with ertin ptients n rete noise or offset voltge prolems. Types of eletroes Monitoring eletroes re single use items with entrl olumn of onutive mteril surroune y plsti fom or pper tpe is or squre to hol the onutive olumn in ple. At the top of the onutive olumn is snp tht the le wire is tthe to, tht goes to the ptient le tht goes to the mplifier. These eletroes ost etween $0.05 n $0.11 eh. If the onutive olumn hs rie out the tre from tht eletroe will e noisy n hs to e reple. ECG reoring Single use reoring eletroes ome in 2 styles, one similr to the monitoring eletroe with onutive gel enter n the other with onutive hesive. Connetion to the onutive hesive eletroe is one 7

8 with n lligtor lip etween the silver-plte king tht the hesive is ple on n the input le. Not ll lips re the sme etween mnufturers n sometimes they will get mixe using onnetion. On ptients tht re swety these onutive hesive eletroes my not stik well using noise. Multi use reoring eletroes ome in severl styles. The most ommon is the plte eletroe tht is hel on to the ptient with ruer elt. Between the eletroe n the ptient s skin onutive gel is ple to ssure goo eletril ontt. A ommon prolem is tht the wrong gel is use, the ultrsoun gel whih is n ousti oupler not n eletril oupler. You n test the gel y putting smll mount on your finger n ru the finger, if you feel grit it is n eletri oupler if not it is ousti. In some institutions sline soke guze p is use inste of the gel, it works ut only for short time. Plte eletroes will orroe over time n rie gel will uil up on the surfe mking the ontt impene inrese whih mke the tre noisier. If plte eletroes re in use they shoul e heke n lene on every PM inspetion tht is one to the mhine. The onnetion etween the eletroe n the ptient le is usully slip fit of soli nn pin t the eletroe, gin sujet to orrosion. The other ommon multi use eletroe is lle the Welh up. This is up shpe silver-ote eletroe with sution ul on the top of it. These re use for otining the hest or V, les. Corrosion is ommon prolem s is the lk of sution s the sution ul ges. It is not unusul to fin the sution ul full of onutive gel n fungus hs een known to grow in the uls. The onnetion to the ptient le is me vi srew lmping onto the soli nn pin t the en of the ptient le. The positioning or plement of the eletroes on the ptient is ritil step, if not properly one it n ompromise the qulity of the ignosti informtion otine, whih often results in the liniin think tht the equipment hs mlfuntione. Points to rememer * Eletroes shoul not e ple on sr tissue * Eletroes shoul not e ple over lot of oy hir; it not only ffets the informtion ut it hurts when the eletroes re remove. * Follow the mnufturer's guielines for eletroe plements. * Eletroes ple loser thn 2 inhes from eh other my strt ross tlk * If more thn one evies requires tht eletroes e ple on the ptient there will e prolems, the est solution is to hve eh evie in ifferent le seletion position, Suh s Les I, II, n III. The linil nee for ll the eletroes shoul e hllenge, in iplomti fshion, y explining tht there proly will e ross tlk etween the evies tht oul ffet the linil outome of the proeure. After the eletroe the wekness link in n ECG system is the le wire, onnetion etween the eletroe n ptient le. While this is multi use wire the grip system to the eletroe n e loose or orroe, whih introues noise into the system. Sometimes the onnetion to the ptient le is lso effete. If le wire is foun efetive it shoul e isre, ut first pull off one en so it will not e use gin. The ptient le shoul lst for mny yers. They often look to e in poor onition euse of tpe resiue on the le. This resiue n e remove using lohol or other solvents. The en of the ptient le tht the le wires onnet will sometimes ontin 10K resistor in series with the le. If this ours it must e on ll onnetions in tht le. Some les esigne for the operting room my hve hoke in series, or to groun with the le wire to reue the effet of eletrosurgil events. It shoul e note tht there is US n Interntionl Stnr for the mplifier onnetor of the ECG le, it is 6- pin onnetor. Unfortuntely mny mnufturers hve seen fit not to follow the stnr so there my e mny ifferent onnetions to ECG mplifiers in hospitl. This n use onfusion with the linil stff n rete some very unusul efforts to mke those onnetions. 8

9 WAVEFORM DISPLAY METHODS There re two generl methos of isplying the ECG wveforms, eletronilly or on pper. In ertin pplitions the wveforms my e store on tpe or in RAM for lter isply, (Holter Monitoring). The storge systems will e isusse in lter setions. ELECTRONIC DISPLAY The most ommon form of eletroni isply is on CRT. The size of the isply n the type of phosphor use in the mnufture of the CRT n enter into the qulity of the wveform. The presenttion of the ECG tre shoul e in the sme formt s pper/hrt presenttion with the newest t losest to the left ege of the isply, often lle moving or soli tre isply. Some mnuftures use n ERASE BAR presenttion, sometimes lle sttionry tre. In this presenttion the wveform is sttionry n lnk spe, or r, moves ross the CRT with the newest t eing to the left of the spe/r. In some oler isplys the tre is not ontinuous ut only lst s long s the phosphor glows fter exittion. This is lle ouning ll isply. The phosphorus will slowly urn off the CRT over yers n the tre will im. To prevent this the tres shoul e repositione on the CRT t lest one per yer. It is not unommon for CRT to lst for mny yers. Unless mge either physilly or internlly the CRT rrely hs to e reple. In ition to the stnr CRT isply mnufturers re now using liqui rystl n pitne isplys tht present t like CRT oes ut re only CM or less thik. These isplys hve life expetnies of 5 to 7 yers n getting longer eh yer. In 10 yers these isplys will proly reple the CRT in most meil evies. All of the eletroni presenttion methos n e set up for TOUCH SCREEN pplitions. In Touh Sreen the perimeter of the isply hs LED s, (light emitting ioes) whih when the em is interrupte ommn is sent to the miroproessor. This system is not prt of the CRT or other type of isply ut seprte omponent tht my hve higher filure rte. If one on the ioes is loke it will effet the isply in some mnor whih will prompt servie ll. It is usully resolve y removing the lokge, generlly tpe or Post-it Note. In rre ses ust will effet the tion of the Touh Sreen. The other ommon metho of wveform presenttion is the Hr Copy. This is pper se with the size n shpe of the pper vrying etween mnufturers. There re four generl types of pper use for wveform presenttion, ink, ly, wx n hemil/therml. Eh hs speifi enefits n prolems. INK pper these ppers hve shinny surfe, with gri lines pre-printe. They n e single sheet or ontinuous strip, roll or z-fol, or ontinuous strip tht n o single sheet. In most ses there re multi hnnels of wveform presente with one or more ECG le onfigurtions per hnnel. The mrking of the les is one with lph hrters or ots n shes. If the stylus is not properly mintine their n e lothing or smuging on the wveforms. WILL NOT WORK WITH HOT STYLUS OR PRINT HEAD PRESENTATIONS. CLAY pper this pper, for hot stylus reorings, is very rrely use s the wx n hemil ppers hve reple it. You will only see this pper on ol units. This pper hs grit on its surfe n will wre the stylus point/ege over yers using wie tre n poor reility of the informtion. This pper only omes in rolls for ontinuous strip reoring. This pper hs pre-printe gri lines. Les re mrke with series of ots n shes long the top ege of the pper. MUST NOT BE USED WITH PRINT HEAD PRESENTATION METHODS. WAX pper this pper, for hot stylus reorings, is not ommon ut is still in use in some lotions. One this pper the stylus het n pressure most ffet the lrity n qulity of the tre. The pper hs 9

10 pre-printe gri lines n only omes mostly in rolls ut in ertin pplitions my ome in z-fol. Les re mrke s on the CLAY pper. MUST NOT BE USED WITH PRINT HEAD PRESENTATION METHODS. CHEMICAL/THERMAL this is the most ommon pper, it omes in roll n z-fol. Its istinguishing feture, in most ses, is no gri lines. This looks like therml fx pper, whih it silly is. This is the only pper tht shoul e use with PRINT HEAD systems. If the pper hs gri lines it n e use with in ple of CLAY n WAX ppers. These ppers ome in vrying withs n vrying numer of hnnels. Unfortuntely single hnnel ppers n vry in with. Pper tht fits H-P my not fit in Spels or Mrquette et. If the pper is too wie it will not fit into the holer, if too nrrow will proly not trk orretly n t will e lost. It is not unommon to fin wrong pper in units. The stnr hnnel with is 50mm, for ECG n Pressure reorings. Other prmeters my e greter or less whih mkes keeping trk of the orret pper for reorers prolem for everyone. GENERAL TROUBLESHOOTING TIP look t the pper first on ny reorer prolem. The hrt spees on most reorers n eletroni isplys re 25 n 50 mm/se. Some my hve itionl spees. When the hrt spee is 25 mm/se eh mm on the horizontl xis is 0.04 seons. The seline of the ECG tre shoul e on the enterline of the hnnel, 25 mm up from the ottom of the hnnel. With pressure tre the ottom line of the hnnel shoul e 0 mm Hg, the top line of the hnnel shoul e the rnge selete for the pressure wveform, 10, 150 or 300 in most ses. With either presenttion metho key trouleshooting tool is the 1mV lirtion utton. This signl is use to lirte the ECG wveform for mplitue or gin. With stnr gin (1000 or 1 on the seletor swith) the pulse shoul e 1m in height. If not you nee to look t the gin, is it set on the stnr, is the unit properly mplifying the signl or is the wveform mpe. On some units the le seletor swith must e in the lirte setting ut on most the 1mv signl n e injete on ny swith seletion. If the wveform is mpe, espeilly on pper presenttions you shoul hek the stylus pressure to the pper. If it is too gret it will mpen the wveform. If the stylus pressure is too light there oul e n overshoot on the leing ege n missing informtion on the ECG tres. This is not prolem with print he systems. In n ICU system the 1mv signl n e use to ssure tht the esie units re ommuniting with the entrl sttion. Simply push the 1mv lirtion utton severl times t the esie, oserve the esie tre presenttion if the wveform is not present there the unit is not working properly n nees to e trouleshot. If the l pulses pper on the esie ut not t the entrl isply there is ommunition prolem. If the wveform is present t oth lotions the system wiring is orret. Note the lirtion pulse shoul lso pper on the reorer t the entrl sttion. RECORDER PRESENTATION As previously overe there re vrious methos of reoring wveforms on to pper. One of the oler methos is the hete stylus. Here s the pper is move over plten point, the stylus, whih is eflete with oth positive n negtive pulses, urns the top surfe of the pper leving the wveform. As overe efore the pressure of the stylus to the pper n ffet the with of the tre n its frequeny response. If too muh het is use the tre will lso e wiene. With inks system the stylus is longer n touhes flt surfe. The ink is rrie vi smll-ore tuing from entrl supply to the stylus. These tues sometimes eome loke n n e lene y removing n flushing them with lohol. This is messy proess n re shoul e tken to protet lothing. The tips of the stylus, (pens), my lso pik up lint n its of pper tht will wien the tre, these shoul e len off the tip using lint free loth or pper. The tip my wer in n uneven mnor n require re-flttening, ommonly referre to s lpping. This is one using very fine piee of emery pper n lightly running the tip over the pper. One fvorite wy of oing this is to put the emery loth uner 10

11 the tip, hol it in ple while moving the position ontrol so the stylus moves ross the emery loth. Only 2 to 3 swings ross the loth re generlly neee to fltten the tip. Ink rtrige systems hve speifilly shpe felt tip mrker inste of hete stylus or ink reservoir. These systems hve the potentil of rying out n not mking full tres. The system is use for oth sttionry pper, (x-y plotter) n ontinuous roll pper. The system hs lower frequeny response n my lose some linil t euse of tht lower frequeny response. Spre rtriges shoul e with the unit s the user n reple them esily. With ge the writing tip my wien n shoul e reple. The print he system is the newest n will e foun on the mjority of evies in use. These units require speil pper, esrie ove, n re must e tken to ssure tht wx n ly pper is not use with these units. From time to time segments on the print he my eome irty n require lening. This n e one with lohol preps. Just expose the print he sie losest to the pper n len y ruing the surfe, gently with the lohol prep. Let the re fully ry efore testing. The tre shoul e of uniform rkness ross the omplex. BLOOD PRESSURE The mesurement of loo pressure hs een ommonly use for over entury n is often misunerstoo. The non-invsive mesurement of loo pressure is omplishe y oluing n rtery, in the upper rm, with n infltle uff tht is onnete to merury mnometer. With the use of stethosope to listen for the Korotkoff s souns of loo flow, s the uff is eflte pressure mesurements re otine. The first soun her is the systoli pressure n the lst soun her is the istoli pressure. The iel pressure is 120 mmhg systoli n 80 istoli. Systoli pressures ove 150 or istoli pressures ove 100 re of linil onern. The ifferene etween the systoli n istoli pressures is lle the pulse pressure. This generlly runs etween 40 n 50 mmhg. The men pressure n e ompute multiplying the systoli pressure y An estimte mens pressure n e otine y ing one thir of the pulse pressure to the istoli pressure. Merury Mnometers A plsti or glss olumn with grutions from 0 to 300 mmhg is onnete to the uff vi ltex or ruer tuing. To get urte reing the tue must e extly vertil. At the top of the tue, uner the p is lfskin iphrgm tht llows ir to move in oth iretions. If this iphrgm is irty the merury in the olumn will not move smoothly, either up or own. MERCURY IS A HAZARDOUS MATERIAL n must e hnle with re. It never shoul e use on hilren, s merury vpors re toxi to eveloping nervous systems. MERCURY MANOMETERS SHOULD BE REPLACED IN HOSPITALS AND CLINICS AS SOON AS FUNDS ARE AVAILABLE The EPA hs set 2005 for ll merury eing out of hospitls. Aneroi mnometer This is ellows se system tht hs il lirte in the rnge of 0 to 300 mmhg. At the resting point of the neele on the il is retngulr ox. If the neele is in tht ox the mnometer is lirte n n e use. The use is the sme s with merury exept the il oes not hve to e vertil. The loo pressure uff is prolem re. If the uff is too smll there oul e n rtifiilly high reing too ig oul proue low reing. If the uff is put on the wrong rm it n proue erroneous reings. It is not unusul to tke loo pressures using thigh uff. It n e iffiult to pik up the soun of loo flow ut in some ptients it is not possile to use the rms. A thigh pressure reing is lso useful in working with ptients tht hve ompromise loo flow to the lower extremities. 11

12 A new tehnique is to tke the loo pressure in the lower leg, just ove the nkle; reports in literture inite tht this pressure is refletive with the Croti rtery pressure leing to the rin. The uff shoul e inspete on yerly sis to ssure ury n repetility in mesurements. The following points nee to e heke. Tue to ler onnetion streth the tue n oserve the juntion with the ler looking for rks n pinholes. If present reple. Tuing streth tuing looking for rking, if present reple Fittings hek to e sure tht they re tight n proper, stopoks shoul not e use. Totl uff inflte to 250 mmhg n llow to stn, the pressure shoul slowly erese t rte not exeeing 5 mmhg per minute. If greter there is lek somewhere in the system Infltion ul Flex ul looking for rking t the juntion with the lee vlve or vent. If present reple Blee vlve when inflte the vlve shoul hol pressure s esrie in the totl uff setion. Also just the vlve so tht the lee own rte is 3 mmhg per seon to test linerity of the vlve. Also fully inflte the system n open the vlve fully, the system shoul totlly eflte in less thn 3 seons. The inspetion proess for the loo pressure uffs is the sme for mnul n eletroni loo pressure mesurement systems where uff is use. With ertin eletroni systems the uff my ontin mirophone, whih is isusse lter. ELECTRONIC BLOOD PRESSURE MEASUREMENT There re evies tht utomtilly n eletronilly mesure loo pressure. The in these system eletronis reples humn in the infltion/efltion of the uff n the listening for or sensing Korotkoff souns. The results re isplye in igitl formt on seprte isplys or on sreen. The units n e progrmme to tke loo pressures on set yle, 1, 5, 15, 30 minutes, tren the t, soun lrms if the results re outsie of preset limits ll without linil person eing present. These evies my e stn lone, omine with other funtions suh s pulse oximetry n temperture or s moule in esie ptient monitor. They my use single or two tues to the loo pressure uff, n the extension tuing etween the evie n the uff my e mnufturer speifi so hek losely if prolem re present. Some evies will hve trnsuer in the evie tht will etet smll pulstion in the uff pressure tht orrespons to ri ontrtions. Other evies will use mirophone in the uff tht onnets to n mplifier in the evie to etet ri ontrtions. RAPID RETAKING OF BLOOD PRESSURES CAN DAMAGE THE VESSELS AND CAN CAUSE INCONSISTANT READINGS. MANY SUGGEST THAT UNLESS IT IS AN EMERGENCY THAT BLOOD PRESSURE NOT BE REPEATED MORE THAN EVERY 5 MINUTES. If you nnot fin prolem with evie tht ws reporte to hve questionle reings this my e the reson. You shoul hek with the user to see if rpi retking of loo pressures ourre leing to the questioning of the equipment. INVASIVE BLOOD PRESSURE MEASUREMENT A theter is introue into vessel, rtery or vein, onnete to trnsuer vi rigi wll plsti tue fille with sline solution tht my or my not hve n nti-ogulnt rug e. The output from the trnsuer is mplifie n isplye s numers, wveform or oth. Sine the skin hs een rehe the ptients first line of efense for oth infetion n eletril shok hve een ypsse. Extreme re must e tken to ssure the sfety of the ptient. 12

13 It is rre for reusle trnsuer to e use. The single use isposle trnsuers re now the stnr of re. Trnsuer ommonly mounte on n IV pole next to the ptient s e. It shoul e t the sme level s the theter in the ptient. There is 2.5 mmhg error for every inh tht the trnsuer is ove or elow the level of the theter in the ptient. During the set up proess the trnsuer is vente to ir n using the flush solution fille with flui, removing ll ir from the system, the vent is lose n the onneting tuing to the ptient is next fille with solution, removing ll ir from tht tue. NOTE THE PATIENT IS NOT CONNECTED AT THIS TIME. The trnsuer vent is gin opene n the mplifier is zeroe. Following the mnufturer s proeures. The vent is now lose n the ptient onnete. If stopoks re use in the system they ll shoul e in the orret position to llow the flush solution to move from the trnsuer to the ptient. A wveform shoul pper on the isply sreen. Flush Solution The solution is in n IV g, whih is ple in either n infltle pressure g, whih is pumpe up to 300 mmhg pressure, or spring loe evie tht mintins the 300 mmhg pressure in the g. The tue from the g is onnete to the flush port of the trnsuer setup n mintins onstnt flow of 2 to 5 ml per hour through the trnsuer to the ptient. The solution generlly ontins n nti-ogulnt, suh s Heprin, whih prevents the tip of the theter from eoming lotte off. From time to time extr flush solution will e ministere to the ptient y pulling the re pigtil or squeezing the flush ontrol on the trnsuer ssemly. This is one to orret ny mping tht my e ourring on the wveform euse of trppe ir or just s preventtive mesure to remove n lotting t the theter tip. FLUSHING MUST NOT BE DONE BY THE BIOMED, ONLY BY A NURSE OF PHYSICIAN. The reson for this is it is ministering rug, whih we re not liense to o. Amplifier Thri Gin of 100 is most ommon Frequeny response 0 to 12 Hz. If the frequeny response is too high there will e ringing on the wveform. You my hve to just the frequeny response to get stle wveform. if ptient hs hert rte ove 120 there n e ringing on the wveform n this will give n rtifiilly high systoli pressure. This n lso hppen if the p/t of the wveform is very short. These oth n generlly e orrete y reuing the frequeny response of the mplifier. The frequeny response is swith seletle on mny mplifiers. The other solution is to introue smll ir ule into the trnsuer. One the ptient s hert rte returns to norml rnges the ringing usully isppers. Pressure rnges rteril 30 to 250 Venous 2 to 50 Centrl venous 1 to 20 (CVP) Pulmonry rtery 4 to 30 (PAP) Wege 2 to 15 Intrrnil 2 to 15 ON INTRACRANIAL PRESSURE MEASUREMENTS NO FULSH SYSTEM SHOULD BE CONNECTED TO THE TRANSDUCER. IF CONNECTED IT CAN KILL. 13

14 In monitoring interrinl pressures (ICP) slight hnges, 2 or 3 mmhg in pressures n le to permnent rin mge so the mehnil zeroing of the trnsuer is very importnt. Pressure onversions 50 mmhg to 1psig 17 mmh20 to 1 mmhg CARDIAC OUTPUT MEASUREMENT The mesurement of ri output is one on ritilly ill ptients in n ICU setting. The system use is lle therml ilution. This is n invsive proeure where long multi lumen theter tht is irete through oth right hmers of the hert into the pulmonry rtery. One lumen hs n opening in the right ventrile n the tip of the theter hs thermistor in it. The liniin will injet olus of sline, 3 to 10 ml into the lumen tht empties into the right ventrile, this sline n e either hille or room temperture on the next ri ontrtion this solution is fore pst the thermistor hnging its resistne. This resistne hnge is onverte into flow mesurement. This mesurement orreltes with the output of the hert in volume. If the evie is esigne for hille injette n room temperture is use there will e n error messge. If prolems our they generlly re result of wrong temperture injette, or injeting too slow. PULSE OXIMETER This is non-invsive metho of mesuring the oxygen level in the loo. It uses speifi light spetrum rets with the issolve oxygen in the loo in liner mnor give the sturtion of the loo with oxygen. The sensor n e ple on finger, er loe, toe or forehe epening upon its esign. Some re single use while other re multi-use. Multi-use sensors shoul e lerly mrke so they o not get thrown wy fter use. Multi-use sensors n ost up to $ Pulse oximeter n either e stn long units, prt of ptient monitor or omine with non-invsive loo pressure n temperture monitors. When not prt of ptient monitoring system the isply of t is either on n LCD or igitl isplys generlly with the ility to set lrms for sturtion levels n hert rte. Note tht the hert rte is not ompute from n ECG omplex ut from the plusitil loo flow pst the sensor. Some of the ommon prolems Amient light Nil polish Col ptient if the sensor is not properly positione mient light my interfere with the etetion of pulses. when finger proes re use nil polish will lok light trnsmission. if the ptient is ol the loo vessels my onstrit mking etetion of loo flow prolem There re no mjor hzrs with this tehnology; it is non-invsive n low power. Most omplints Involve the hesive use to hol the proe in ple or the pressure on the finger/toe with multi-use sensors. Pulse Oximeter Proly no evie hs h suh wie spre n quik eptne into linil instrumenttion in the lst 20 yers thn the pulse oximeter. The moern Pulse Oximeter shoul not e onfuse with the er oximeter, whih ws mrkete y Hewlett-Pkr in the mi 70 s. The tehnology is quite ifferent the ol system whih use 8 wvelength etetors oul only e use on the er loe; require heting of the re n it ws not portle. Another erly version from Minolt use fier opti le for light trnsmission n etetion s they were too ig to e put into proe tht oul e, omfortly pplie to the ptient. Muh of the originl work on the pulse oximetry ws to evelop non-invsive metho of etermining ri output. The sie effet of getting goo orreltion on loo oxygen levels prove to 14

15 e the mrketle prout n reserh on using the tehnology for ri output silly stoppe. An urn legen evelope sying tht oth the pulse oximeter n Vigr were sie effets of the prime ojetive of the engineering work, one mesuring ri output n the other inresing it. The moern pulse oximeter owes muh of its suess to Dr. Willim New who introue the Nellor unit in the mi 80 s. Ohme introue the Biox II in the mi 80 s utilizing miroproessors ws nother mjor ftor in the utiliztion of pulse oximetry. Aitionl reit hs to go to the mlprtie insurne ompnies tht tol nesthelogists tht if they use pulse oximetry tht their premiums woul e reue. The pulse oximeter works on resonly simple priniple of light sorption, s efine in the Beer- Lmert lw or Bouguet s lw epening on the textook use. Bsilly it sttes tht light is sore or psse through solution se on the onentrtion of the hemil in the solution for ertin light wvelength. It ws foun tht hemogloin, (H), non-oxygente loo whih is rk re in olor, n oxyhemogloin, (HO2), oxygente loo whih is right re in olor, hve ifferent light sorption levels. By using 2 etetors one in the 660nM rnge to mesure hemogloin n the other in the 940nM mesuring the oxyhemogloin long with proprioretory lgorithms urte linil results on loo oxygen oul e otine. Pulse oximeters hve some limittions s mient light n ffet the reings, s n shivering, low flow, very thik skin n poor plement of the sensors. Most of the newer esigns, fter 1998, hve muh etter rejetion systems for motion rtifts. When the finger is use s the lotion of the proe, it is importnt tht the light soure e ple on the nil n the etetor on the soft tissue of the finger. Neeless to sy the ptient shoul not hve nil polish on. A ptient with ron monoxie exposure will register flsely high on oxyhemogloin s the loo will e very re. For these ptients o-oximetry or en til CO2, (pnometry) will give etter linil results. The wie spre of pulse oximetry hs inrese ptient omfort in tht mny fewer loo gs mesurements re me now thn in the pst. If you hve ever h n rteril stik for loo gs you know tht it is quite pinful. The iret monitoring of loo pressure, nother soure of getting smples for loo gs tests, is lso own in mny hospitls. There re some prolems tht the Biome still hs to respon to with pulse oximeters. B sensors n les re proly the most ommon. Some shops will reproess the sensors n etetors on isposle units, e reful on this s you my eome mnufturer in the eyes of the legl system n e without insurne protetion. Other prolems inlue tteries, white tpe, (white tpe shoul e ontrolle sustne), oune tests, (most units o not oune well off the floor) n we nnot fin it on the floor so you must hve it in the shop. To nme few of the more ommon lls we get. On some monitoring systems the pulse oximeter is use s the seonry lrm if the ptient is eing pe, either externlly or internlly. This n present prolem s the ptient monitor my not soun n lrm ut only hve sreen flsh if the lrm limit on the pulse oximeter is triggere. Tke little time uring the next PM yle on the monitors to onfirm how the lrms ret when ptient is eing pe. In losing plese e wre of where the lrm limits n e set for the low lrms on your units oth in the stn-lone evies, in monitoring systems n in multi-purpose stn lone units. Most of us just hek the efult setting n o not try to just the limit own elow 90. Some mnufturers will llow the user to hve lrm limits s low s 50. So tke the time to hek the limits. DEFIBRILLATORS The efirilltor elivers energy to ptient t level tht will re-polrize the hert, stop unontrolle eting n return the hert to norml sinus rhythm. If ll tivity in the hert hs stoppe the energy will sometimes restrt the hert. The energy elivere is mesure in joules, on some oler units the energy my e lele s wtts or wtt/seons. A pitor is hrge n when ishrge through LCR iruit to the ptient the pulse n rnge up to 15

16 7,500 volts t 50 to 60 mps, ut the pulse with is only few milli-seons. One the hrge hs een trnsferre to the ptient the evie will not utomtilly rehrge, it requires mnul tion of pushing the hrge utton. This is for opertor sfety. The 3 most ommon efirilltor wveforms in use, the Emrk, Lown, n Biphsi. The urrent ntionl stnrs ll for ll efirilltors to work the sme, 1,2,3. Bsilly 1 is to turn the unit on n selet energy to e elivere, 2 is to press the hrge utton, my e on front pnel or ples, ple ples on ptient n ishrge, uttons on ples. Some efirilltors hve the option of using efirilltor eletroes tht re ple on ptients hest efore proeure strts, with these units the ishrge utton is on the front pnel or in the le ssemly. The other steps remin the sme. The efirilltor shoul never e ishrge y putting the two ples or eletroes together n pushing the ishrge swith. At minimum this will mge the ples n potentilly the unit. If the unit is not ishrge into ptient use the test lo on most efirilltors or let the unit ishrge internlly. This will our in 10 to 15 seons fter the unit is hrge. It only tkes few seons for the units to hrge so there is no reson to leve them in the hrge moe, it is ngerous to the users. Defirilltor ples ome in 3 types, externl ult n peitri sizes, internl ples tht re vrious sizes use when the hest is open, (open hert surgery), n eletroe. Most efirilltors will ept ll types. The gel use to ssure onution etween the ples n the hest wll will sometimes uil up on the ples n hve to e lene. Alohol will soften the gel n mke removl esy. The externl ples shoul e inspete for pit mrks, these oul use high urrent ensity n leve urns on the hest. The mrks n e remove using emery pper. Internl ples shoul e inspete to e sure tht there re no reks in the insultion roun the onutive prt of the ple. If reks re present the ples shoul not e use. The eletroes re pre-gelle n re single use. The ptient n e urne if the eletroes re reuse on nother ptient. Eletroes re use with the AED iphsi units tht re eoming more ommon in non-meil res, plnes, theters, sporting events, et. Btteries shoul e reple every 24 months, or less, to ssure proper opertion of the efirilltor. CARDIOVERSION Crioversion is the pplition of the output of the efirilltor to ptient t speifi point in the ECG omplex. The power is lower n the ptient must hve n ECG omplex ontining n R wve. The ptient is onnete to n ECG mplifier tht hs speil iruit tht sens pulse to the efirilltor to ishrge t prtiulr point of the ECG omplex. When oserving the sreen or tring of the ECG you will notie flg on the wveform initing the spot where the ishrge shoul our, light on the front pnel shoul lso e flshing. The linil person will ple the ples, or efi eletroes, on the ptient n push the ishrge uttons. The linil person my hve to hol the utton in for severl ets efore the efirilltor will ishrge. The ptient shoul e sete or uner nesthesi for this proeure s it is pinful. The energy level use in rioversion is uner 150 joules. The norml strting point is 50 n if the prolem is not orrete higher levels will e use until the rrthymi is orrete. Normlly the ptient will lso e reeiving rug therpy for the onition. In severe ses the ptient hve to hve efirilltor implnte. There is sfety lok system on the unit so tht the efirilltor nnot e left in the rioversion or syn moe. If it were the unit woul not work s norml efirilltor s it woul e looking for n R wve to trigger off of generlly in 50 milli-seons or less. 16

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