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Please Review This Video for an Introduction

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Please Review This Video for an Introduction

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ALERT

Ensure the proper placement of electrodes to avoid incorrect interpretation of the 12-lead electrocardiogram (ECG), mistaken diagnosis, or patient mismanagement.undefined#ref2">2

OVERVIEW

The standard 12-lead ECG is the most widely used noninvasive diagnostic tool in the management of cardiac disease and is a source of information about the heart's electrical system.2 The ECG has significant impact on medical decision-making, clinical management, and therapy. Common uses include diagnosing acute coronary syndromes, identifying arrhythmias and conduction disturbances, and determining the effects of medications or electrolytes on the heart's electrical system ( Box 1).

The ECG leads are the standard limb leads (I, II, III); augmented limb leads (augmented vector right [aVR], augmented vector foot [aVF], and augmented vector left [aVL]); and six chest leads (V ₁ to V ₆). The standard and augmented leads view the heart from the vertical or frontal plane ( Figure 1), and the chest leads view the heart from the horizontal plane ( Figure 2). The graphic display consists of the P, Q, R, S, and T waves, which represent electrical activity in the heart.2

If myocardial ischemia or injury is suspected, serial ECGs are performed. Correct standardized electrode placement is crucial for accurate ECG interpretation.3 Advances in technology allow online or wireless transmission, networking capabilities, and computerized interpretation of the 12-lead ECG.

SUPPLIES

See Supplies tab at the top of the page.

EDUCATION

Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.

Explain the equipment and the procedure.

Instruct the patient not to talk, to relax, to lie still, and to breathe normally.

Encourage questions and answer them as they arise.

PROCEDURE

1. Perform hand hygiene. Don appropriate personal protective equipment (PPE) based on the patient's need for isolation precautions or the risk of exposure to bodily fluids.

2. Introduce yourself to the patient.

3. Verify the correct patient using two identifiers.

4. Explain the procedure and ensure that the patient agrees to treatment.

5. Ensure that evaluation findings are communicated to the clinical team leader per the organization's practice.

6. Ask if the patient is experiencing chest pain, shortness of breath, or palpitations.

7. Ask about the patient's history of cardiac arrhythmias or cardiac problems.

8. Ask the patient about any current medications.

9. Ask the patient to remove any jewelry (e.g., wristwatches, necklaces, body jewelry) that may interfere with the ECG.

10. Check the cables and lead wires for fraying, broken wires, or discoloration.
Rationale: Checking the cables and lead wires helps detect conditions that may give an inaccurate ECG tracing.

If equipment is damaged, obtain alternative equipment and notify the appropriate health care team member for repair.

11. Plug the ECG machine into a grounded alternating current (AC) wall outlet or ensure that the battery-operated machine is functioning.

12. Turn the ECG machine on and input the required information.
Rationale: Equipment may require a self-test and warm-up time. Multichannel machines (Figure 3) may require input of information (e.g., data about the patient) to store the ECG appropriately.

Follow the manufacturer's recommendations and requirements for inputting information and warm-up time.

13. Assist the patient into a resting, supine position. Ensure that the patient is not touching any side rails or footboard, as applicable.
Rationale: The supine position provides adequate support for the patient's limbs so muscle activity is minimal. Touching side rails or a footboard may increase the chance of distorting the tracing. Body position changes can also cause alterations in the ECG tracing.

The supine position is best, but Fowler or other positions may be used for comfort. Ensure that serial ECGs are recorded with the patient in the same position, so changes in body position do not cause changes in tracings. If another position is required clinically, document the position on the tracing or in the comment space of the machine input.

14. Expose only the necessary parts of the patient's legs, arms, and chest to provide privacy and warmth.
Rationale: A lack of privacy may induce anxiety, which can alter the ECG reading. Shivering interferes with the recording.

15. Identify the lead sites before placement.
Rationale: Identifying and marking the lead sites ensures that the electrodes are accurately placed.

16. Wash the patient's skin with soap and water and dry it briskly with gauze pads or a washcloth.1 Ensure that the patient's skin is dry before applying the electrodes.
Rationale: Moist skin is not conducive to electrode adherence. Wiping the electrode area with a washcloth or gauze dries and roughens the skin to enhance conduction.1

Do not use alcohol for skin preparation because it can dry the skin.1

To ensure good skin contact with the electrodes, clip chest hair with surgical clippers as necessary.

17. Prepare the electrodes.
Rationale: Preparing the electrodes allows appropriate impulse conduction.

1. For pregelled electrodes, remove the backing and test for moistness.
Ensure that the gel is moist. Replace the electrodes if they are not moist.

2. For adhesive electrodes, remove the backing and ensure that the adhesive pad is sticky or moist.
Replace adhesive electrodes if they are not sticky.

18. Place the limb electrodes (Figure 4) in fleshy areas, equidistant from the heart and in approximately the same place on each limb. Avoid bony prominences.
Rationale: Accurate placement ensures correct electrical tracing of the heart from the vertical and frontal planes.2

19. Place the chest electrodes (Figure 5), ensuring accurate placement.
Rationale: Accurate placement ensures correct electrical tracing of the heart from the horizontal plane. Slight alterations in the position of a precordial lead may alter the ECG significantly and can have an impact on diagnosis and treatment.2

1. Identify the sternal angle, also called the angle of Louis (Figure 5).
Rationale: The sternal angle helps identify the second rib for placement of precordial leads in the appropriate intercostal spaces (ICSs).

1. Palpate the upper sternum to identify where the clavicle joins the sternum (suprasternal notch).

2. Slide the fingers down the center of the sternum to the obvious bony prominence; this is the sternal angle, which identifies the second rib and provides a landmark for locating the fourth ICS.

2. When the fourth ICS is located, place the V electrodes in the appropriate locations.

1. V₁ at the fourth ICS, right sternal border

2. V₂ at the fourth ICS, left sternal border

3. V₄ at the fifth ICS, midclavicular line

4. V₅ horizontal to V₄ at the anterior axillary line

5. V₆ horizontal to V₄ at the midaxillary line
Variations in precordial lead placement can result in important diagnostic errors, such as septal ischemia or infarction.2

If leads cannot be accurately placed, clearly document the actual location of the electrode placement on the 12-lead ECG.

Place precordial electrodes under the breasts of a patient with large breasts.

20. Attach the lead wires to the electrodes.

21. Turn the ECG machine on and program it according to the manufacturer's instructions. Most machines have automatic settings for programming paper speed and calibration and to perform a self-test when turned on.

22. Input patient information required for appropriate storage of the ECG into the machine according to the organization's practice.

23. Obtain a 12-lead ECG recording.

1. Instruct the patient to remain still while the machine senses and translates the heart's electrical activity to electrical waveforms on paper.
Rationale: For correct interpretation, the ECG must be marked accurately and have a clear baseline without artifact.2

2. Obtain a rhythm strip if needed.
Rationale: A rhythm strip is a long recording of a specific lead; lead II is commonly used because P waves are best seen in lead II.

Refer to the manufacturer's instructions for use (IFU) on obtaining a rhythm strip.

24. Examine the 12-lead ECG tracing to ensure that it is clear and without artifact; repeat the ECG if it is not clear. Compare the 12-lead ECG with previous 12-lead ECGs if possible.
Rationale: A comparison helps determine normal and abnormal findings.

Examine the ECG and determine whether the recording must be repeated while the patient is still connected to the machine.

25. The clinical team leader interprets the recording, per the organization's practice, and looks for:

1. Rhythm

2. Rate

3. Presence and configuration of P waves

4. Length of P-R intervals

5. Length of QRS complexes

6. Configuration and deviation of the ST segments

7. Presence and configuration of T waves, length of Q-T intervals, presence of extra waves (e.g., U waves)

8. Arrhythmias

9. Signs of ischemia, injury, infarct, and other significant myocardial alterations
Rationale: An evaluation identifies pathophysiologic processes that may require further evaluation or treatment.

26. Disconnect the equipment, clean the gel off of the patient (if necessary), return removed clothing, and help the patient resume a comfortable position.
Follow the manufacturer's IFU and the organization's practice for electrode use and removal.

27. Clean the ECG leads and machine per the manufacturer's instructions and the organization's practice. Return the equipment to its assigned storage space.

28. Discard supplies, remove PPE, and perform hand hygiene.

29. Document the procedure in the patient's record.

EXPECTED OUTCOMES

A clear 12-lead ECG recording (Figure 6) is obtained.

Abnormalities are promptly identified.

UNEXPECTED OUTCOMES

Altered skin integrity

Inaccurate lead placement or limb lead reversal (Figure 7)

AC interference, also called 60-cycle interference (Figure 8)

Wandering baseline (Figure 9)

Motion artifact (Figure 10)

DOCUMENTATION

Education

Reason for the 12-lead ECG (documented by the clinical team leader)

Patient signs and symptoms of cardiac arrhythmias or cardiac problems (e.g., chest pain, syncope, dizziness, palpitations)

Any altered lead placement or patient position and reason for change

Follow-up to the 12-lead ECG, as indicated

Unexpected outcomes and related interventions

Evaluation findings communicated to the clinical team leader per the organization's practice

1. American Association of Critical-Care Nurses (AACN). (2018). AACN practice alert: Managing alarms in acute care across the life span: Electrocardiography and pulse oximetry. Critical Care Nurse, 38(2), e16-e20. doi:10.4037/ccn2018468 (Level VII)

2. Brady, W.J., Harrigan, R.A., Chan, T.C. (2019). Chapter 14: Basic electrocardiographic techniques. In J.R. Roberts and others (Eds.), Roberts and Hedges' clinical procedures in emergency medicine and acute care (7th ed., pp. 275-287). Philadelphia: Elsevier.

3. Sandau, K.E. and others. (2017). Update to practice standards for electrocardiographic monitoring in hospital settings: A scientific statement from the American Heart Association. Circulation, 136(19), e273-e344. doi:10.1161/CIR.0000000000000527 (Level VII)

Elsevier Skills Levels of Evidence

Level I - Systematic review of all relevant randomized controlled trials

Level II - At least one well-designed randomized controlled trial

Level III - Well-designed controlled trials without randomization

Level IV - Well-designed case-controlled or cohort studies

Level V - Descriptive or qualitative studies

Level VI - Single descriptive or qualitative study

Level VII - Authority opinion or expert committee reports

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Elsevier – Clinical Skills │ Electrocardiogram: 12 Lead (Ambulatory) - CE

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Ensure your knowledge on electrocardiograms follow the latest clinical guidelines and reflective of best practices.

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Citation: https://aimcardio.com/blog/12-lead-placement-guide-with-diagram/

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Pull facility policy and procedure on obtaining a 12 lead EKG. Review prior to entering patients room

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Perform hand hygiene, done appropriate personal protective equipment based on patient need and introduce yourself to the patient and family.

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Verify correct patient using two hospital approved identifiers, explain the procedure and ensure understanding. If further education is needed, ask for appropriate staff member to come and educate patient and or family

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Ask the patient to remove any jewelry, street clothes and to lay on their back (Supine). Ensure patient is not touching any side rails or metal surfaces as it could interfere with the electrical tracing. Expose only necessary parts of patient body (arms, legs, chest), always ensuring privacy.

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Turn on EKG Machine and begin placing electrodes in correct positions.

V1 - 4th intercostal space, to the right of the sternal border

V2 - 4th intercostal space, to the left of the sternal border

V4 - 5th intercostal space, at the left midclavicular line (middle of the clavicle)

V3 - Directly between V2 and V4

V5 - Horizontal to V4 at the anterior axillary line (straight down just in front of the armpit)

V6 - horizontal to V4 at the midaxillary line (straight down from the armpit)

RA - On the right arm, in a fleshy area, avoiding bony prominences

RL - On the right leg, in a fleshy area, avoiding bony prominences

LA - Parallel to RA on the left arm, in a fleshy area, avoiding bony prominences

LL - Parallel to RL on the left leg, in a fleshy area, avoiding bony prominences

After the electrodes are placed, attach the correlating lead wires to the appropriately placed electrode.

Reference for picture: https://www.researchgate.net/figure/ECG-electrode-placement-The-name-and-placement-of-the-standard-ten-electrodes-used-to_fig1_371052743

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After placing electrodes on the patient's chest, and then connecting the appropriate cord to the ECG Machine, you will want to do a quick look at the waveforms on the machine. Green indicates a good electrical flow, orange or red indicates the connection is not accurate. Now is the time to ensure all electrode stickers are adhered to the chest and cords are connected.

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Assure the ECG machine is on and programmed to all manufacturers specifications, including patient information. Instruct the patient to exhale and not take a breath in for just a second. After the patient exhales, push the button to record the ECG.

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Step 8: Remove Electrodes and Deliver ECG

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Step 8: Remove Electrodes and Deliver ECG

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Disconnect the leads from the patient, then remove the electrode stickers. (If a patient is required to have multiple ECGs in one day, also known as serial ECGs, you can leave the electrode stickers in place).

Clean the ECG Machine as required by manufacturer and hospital. Document appropriately in the patients medical record.

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Understanding Electrocardiograms and Stress Tests

What is an electrocardiogram (ECG)?

An electrocardiogram (ECG or EKG) is one of the simplest and fastest procedures used to assess the heart. Electrodes (small, plastic patches) are placed at certain locations on the child's chest, arms and legs. When the electrodes are connected to the ECG machine by lead wires, the electrical activity of the child's heart is measured. The cardiologist uses this information to decide whether the child needs further tests or the proper course of treatment for the child's heart problems.

Why is an ECG performed?

The electrical activity of the heart is measured by an electrocardiogram. By placing electrodes at specific locations on the body (chest, arms, and legs), our specialists can get a "picture," or tracing, of the electrical activity in the heart. Changes in an ECG from the normal tracing can show one, or more, of several heart-related conditions. Learn more about the electrical system of the heart. Some medical conditions that can cause changes in the ECG pattern include, but are not limited to, the following:

Conditions in which the heart is enlarged. These conditions can be caused by various factors, such as congenital (present at birth) heart defects, valve disorders, high blood pressure or congestive heart failure.

Ischemia. A decreased blood flow to the heart muscle due to clogged or partially-clogged arteries.

Conduction disorders. A dysfunction in the heart's electrical conduction system that can make the heart beat too fast, too slow or at an uneven rate.

Electrolyte disturbances. An imbalance in the level of electrolytes, or chemicals, in the blood, such as potassium, magnesium or calcium.

Pericarditis. An inflammation or infection of the sack that surrounds the heart.

Valve disease. Malfunction of one or more of the heart valves that may interfere with blood flow within the heart.

Chest trauma. Blunt trauma to the chest, such as that suffered in a car accident.

An ECG may also be performed for other reasons, including, but not limited to, the following:

During a physical examination to obtain a baseline tracing of the heart's function. (This baseline tracing may be used later as a comparison with future ECGs, to see if any changes have occurred.)

As part of a workup prior to a procedure, such as surgery, to make sure no heart condition exists that might cause complications during or after the procedure.

To check the function of an implanted pacemaker.

To check the effectiveness of certain heart medications.

To check the heart's status after a heart-related procedure, such as a cardiac catheterization, heart surgery or electrophysiological studies.

What is the procedure for an ECG?

An ECG can be performed almost anywhere, as the equipment is very compact and portable. At CHOC we provide ECGs in our Heart Center, as well as the inpatient unit of the hospital and the Julia and George Argyros Emergency Department at CHOC. Our specialists even take ECG equipment to local schools to test athletes. The equipment used includes the ECG machine, skin electrodes and lead wires that attach the electrodes to the ECG machine. An ECG normally takes approximately five to 10 minutes, including attaching and detaching electrodes. Getting an ECG typically includes the following steps:

The child lies flat on a table or bed for the procedure.

The ECG technician uncovers child's chest only exposing the necessary skin.

Electrodes (small, plastic patches) are attached to the child's chest and one electrode is attached to each arm and leg.

The lead wires are attached to the skin electrodes.

Once the leads are attached, the technician may key in identifying information such as the child's name and age into the machine's computer.

The ECG is started. The child must lie still and not talk during the procedure, so as not to interfere with the tracing. Caregivers can usually be present in the room and involved in reassuring and encouraging their child during the procedure. At this point, it will take only a few minutes (or less) for the tracing to be completed.

Once the tracing is completed, the technician will disconnect the leads and remove the skin electrodes.

Depending on the results of the ECG, additional tests or procedures may be scheduled to gather further diagnostic information.
How is the exercise ECG test performed?

At CHOC, stress tests are performed on the third floor of the hospital in our Heart Center. The equipment used includes an ECG machine, electrodes (small, plastic patches that stick on the skin), and lead wires which attach to the skin electrodes. A blood pressure cuff is also used to monitor your child's blood pressure response during exercise. A treadmill or stationary bicycle is used for exercise. Each child has an initial, or "baseline," ECG and blood pressure readings done prior to exercising. He or she will walk on the treadmill or pedal the bicycle during the exercise portion of the procedure. The incline of the treadmill will be gradually increased, or the resistance of the bicycle will be gradually increased, in order to increase the intensity level of exercise. The ECG and blood pressure will be monitored during the exercise portion of the test. Symptoms are also carefully monitored during exercise. The child will be asked to exercise only to the best of his or her ability. Following exercise, ECG and blood pressure readings are monitored for a short time, perhaps another 10 to 15 minutes or so. The procedure will take approximately one hour, including check-in, preparation and the actual procedure. After the procedure, a hospital stay is not necessary, unless your child's doctor determines that the child's condition requires further observation or hospital admission. The child may feel a little tired or sore for a few hours after the procedure, particularly if he or she is not used to exercising. Otherwise, the child should feel normal within a few hours after the procedure, if not sooner. Depending on the results of the exercise ECG, additional tests or procedures may be scheduled to gather further diagnostic information.

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Electrocardiograms (ECG) - Children's Hospital of Orange County

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An electrocardiogram (ECG or EKG) is one of the simplest and fastest procedures used to assess the heart.