Placement of ECG Leads

[AnthonyM83]

I was wondering where people prefer to place their EKG leads when doing a 3-lead and and 12-lead.

I was told close to the chest has the fewest artifacts, prime location being directly surrounding the heart for Leads I, II, and III., though it's easier to just put them at shoulders and waist. Would putting them too close make it harder to read the rhythm at all?

When patching someone up for a 12-lead, I've been told to put Lead I, II, III (Black/White/Red/GreenGrounding) on the extremeties, even though they weren't blocking placement of the six 12-lead electrodes. I thought the only reason for putting them on extremities was to leave space on the chest....doesn't interfere with 12-lead, right?

And finally, If you put top electrodes on arm, must you put bottom ones on feet or can they go on waist area? If you put top electrodes on shoulders, can bottom ones go on feet? Do top and bottom have to match or just worry about left/right matching.?

Thanks

[akflightmedic]

Well, they are called LIMB leads for a reason. One might even suspect that they are supposed to go on the LIMBS.

So with that in mind, anyone you are putting on a monitor, should definitely get a 12 lead. So, always put them on the limbs to start with as that is the most practical and appropriate placement.

Yes there are times where for some odd reason this is not practical or easy to do, but yes proper placement of the limb leads should be on the limbs. Also, there is less movement as they can hold their limbs still and not cause interference, whereas if they are on the chest, their abdomen and chest is moving which can cause a poor readout.

Different situations you listed: Yes you could have limb leads on the arms and the other two on the waist or two on the legs and two at the top of the chest.

In addition, placing extremity leads on the extremities is not "to make room" for the 12 lead as the 12 lead electrodes have very specific placements and properly placed limb leads will not interfere with this.

For a nice, pretty 12 lead, proper placement is very important. Variances can occur on a printout due to misplacement of the 12 lead electrodes. Most of these variances are easily recognized, however we should always strive for proper placement. It really annoys me to see medics slapping on patches with no regard as to the correct, proper placement.

There are always slight exceptions or circumstances that require deviating from this, but consistency is the key.

As mentioned before, get a nice reference book and read up on electrode placement. You will be amazed at the history behind electrodes/ECGs and how important proper placement is. Dale Dubin does a great job on this, yes there are many others that are good too, but I liked his best. Please do not do any spinoffs or thread hijackings debating the man's character, as I keep his personal life seperate from the knowledge has has imparted upon us.

[AnthonyM83]

Well, they are called LIMB leads for a reason. One might even suspect that they are supposed to go on the LIMBS.

That's what I thought, too, but then did some reading and saw Einthoven's triangle where it said "For Lead II, the positive electrode is usually placed at the apex of the heart on the chest wall (or on the left leg" (Bledsoe, 2006). Basically, there seems to be so many contradictory statements and explanations both from books and medics, that I don't know which is best in practice.

[Dustdevil]

...but then did some reading and saw Einthoven's triangle where it said "For Lead II, the positive electrode is usually placed at the apex of the heart on the chest wall (or on the left leg" (Bledsoe, 2006).

You'll notice that he is very specifically addressing Lead II only. If all you are doing is monitoring a rhythm strip, then torso placement is fine. And it does cut down on artifact. But for a diagnostic and/or 12 lead tracing, it is extremely important that the LIMBS be used. It makes a significant difference. You can literally miss an MI by improper placement, so don't ever half-arse it.

I encourage you to test this out for yourself. On the next few patients you have where you have the luxury of time, try it both ways. Run your diagnostic on the Limbs. Then, during transport maybe, run it again with the limb leads on the torso. Compare the two tracings and you should see a difference, usually a significant one. And it doesn't take much difference to change your diagnosis.

There ya go, Anthony. Now you know more than probably seventy-five percent of the medics in LA County. :wink:

[Riblett]

Manufacturers recommend that RL, RA, LL, and LA be placed on their respective limbs. Instructors should be teaching you this in school and while precepting in the field. However, if you spend any time on a truck you will see that the majority of medics, especially those who have been in for a while, will place them on the torso.

When the leads are placed on the torso you tend to get significantly less artifact. But the view can be skewed by improper lead placement, particularly when doing more sensitive diagnostics such as axis deviation and ventricular hypertrophy. However, if you are doing just dysrhythmia monitoring it is probably okay to place them on the torso.

Personally I place them on the limbs, but as close to the torso as I can. I put the arm leads on the deltoid area and limb leads on the thighs (clothing permitting). This way you should have minimal artifact caused by limb movement and the accurate view that limb placement provides.

[celticcare]

It all depends on the way the monitor has been calibrated and whether the amplitude has been set to allow the limb leads to be placed on the torso. There are settings you can adjust on your monitors to allow this so you can have a patient conected to a 12 lead for conitnual analysis and have the limbs free for IV's etc.

Yes the limb leads should ideally be placed on the limbs, however practicality can make this a different reality. Check the monitor guidebook for further information on this.

[FireMedic65]

I was also told by a cardiologist that when placing the leads on the patient, it is a good idea to mark where you put the leads when they are in the proper places. His explanation for this was when transferring a patient, and the stickies come off the patient which we all know they do, they should be put back in the same place.

As Dust said lead placement for diagnostics if very important. If the leads get moved around from one analysis to another, the outcome could be different. If they are put on properly by us, we might see the MI, but a lead coming off and being put back on in another location, that MI might not show up again.

[tom5706]

I was also told by a cardiologist that when placing the leads on the patient, it is a good idea to mark where you put the leads when they are in the proper places. His explanation for this was when transferring a patient, and the stickies come off the patient which we all know they do, they should be put back in the same place.

As Dust said lead placement for diagnostics if very important. If the leads get moved around from one analysis to another, the outcome could be different. If they are put on properly by us, we might see the MI, but a lead coming off and being put back on in another location, that MI might not show up again.

You may want to watch this 2 part video that Tim Phalen published. A bit "Hollywood" but I found it a good guide. Like the thread says..."whatever works for you"

[nikipoo]

So does it matter whether or not you place the RA/LA leads on the upper arm or by the wrist? I regularly do EKG's as part of paramed PE with two different companies, one comp taught us to put them on the upper arm, the other taught us to put them by the wrist.

[celticcare]

So does it matter whether or not you place the RA/LA leads on the upper arm or by the wrist? I regularly do EKG's as part of paramed PE with two different companies, one comp taught us to put them on the upper arm, the other taught us to put them by the wrist.

Again as said above, check your monitors settings and check that they are calibrated to the wrists or the torso. That will make a difference. Its down to an eye to see as well and being aware of transient acute coronary syndrome symptoms *such as apical ballooning and coronary artery spasm*.

It's not all about the STEMI either, its all about your systematic review of the 12 lead and following a sequence to interpret it.

Scotty