1

Twelve Tips for 12 Leads

Jacky Vaniotis, RN, NREMT-P

Services all across the state are getting in on the 12 lead excitement. Providers are taking
12 lead classes to learn to interpret cardiograms, talking to each other about axis deviation,
ST segment elevation and contiguous leads. But before any 12 lead can be interpreted it
needs to be obtained. And the tracing must be a good one for it to be meaningful. The
following tips will help with the process of obtaining a good tracing.

1. Location, Location, Location

Look at any textbook that talks about obtaining 12 lead EKGs, and every single one of
them will show you proper placement of EKG leads. So why, then, do we so often see
patients with their V1 and V2 leads placed just below the clavicles, or V4, V5 and V6 sitting on
the patients abdomen?!

Remember, the electrocardiogram is looking at electrical activity moving from one pole
to another, so if the leads are not placed where they belong, the tracing will not show an
accurate representation of that activity!

2. Limb Leads
There is much disagreement in the literature about the best location for the limb leads.
Some resources say they must be placed distally on the limbs (wrist and ankle), some say it
doesnt matter if they are distal or proximal as long as they are on the limbs. Some say they
can be on the trunk as long as they are far enough from the heart. Some resources say its
better to place the leads over bone because you get less muscle tremor, others say to place
them over soft tissue and recommend that they not be placed over bone...

In general, however, the four limb leads should be placed on guess what the four
limbs! You should place them on soft tissue, not directly over bones. The soft tissue of the
medial surface of the calves and the meaty area in the middle of the forearm are ideal. (In
situations in which you cant, or choose not to, use those distal areas, for example, on a
patient with Parkinsons who cant control his tremors, the best you might be able to do is to
make sure that your limb leads, while on the trunk, are as close to the corresponding limbs as
possible.)

3. Chest Leads
While there may be much debate about placement of the limb leads, there is universal
acceptance that the placement of precordial (chest) leads is extremely important, and must be
precise, correct and consistent. For example, if you want something thats going to view the
electrical activity moving toward the septum and anterior portion of the heart, you need to
have your leads placed directly over the septum and anterior portion of the heart. So Leads V1
 2

and V2 need to be placed at the fourth intercostal space, V1 immediately to the right of the
sternum and V2 just to the left.

To find the fourth intercostal space for V1 and V2, start at the space just below the
clavicle, which is the first intercostal space, and palpate down (yes, you must actually touch
the patients chest!) to the second, third, then fourth space. Alternatively you could feel for
the bump on the sternum, the angle of Louis, which sits at the second rib. Immediately
lateral to the angle of Louis is the second rib, and just inferior to that is the second intercostal
space; you can continue to count down from there.

You skip V3 at this point, and place V4 next. V4 goes at the mid-clavicular line in the fifth
intercostal space. Put your finger on the middle of the clavicle to get a sense of where the
midclavicular line is. Now go back to where you put V2 and move down one rib to the fifth
intercostal space and follow that to the midclavicular line, then put V4 there. (Dont let
anybody tell you V4 goes just below the nipple line. While it may work for most men, in
women nipple lines tend to migrate downward and outward as they age, and therefore the
nipple line cant be used as a consistent landmark!) Next, V3 is going to go directly in the
middle of the imaginary line between V2 and V4.

Again, youre going to skip V5 and go to V6, which gets placed in the mid-axillary line at
the fifth intercostal space. V5 then goes directly in the middle of the line between V4 and V6,
which just happens to be at the anterior axillary line.

One mistake many people make is to curve V5 and V6 upward toward the axilla, as if to
circle around the breast like an underwire bra. This puts V5, and especially V6, too high for
correct placement. V4, V5, and V6 should all be in essentially a horizontal line.

Another mistake people make is to want to keep all the electrodes equi-distant from each
other. Remember your landmarks, and you wont fall into that trap.

4. Mama Mia!
Women, of course, present a bit more of a challenge than men do because of their breast
tissue that often gets in the way. You do need to remove a womans bra, and lift her breast out
of the way in order to place the stickies, especially V4 and V5. If you are uncomfortable about
touching her breast, or afraid of making her uncomfortable when you do so, you might try
placing a sheet across her upper chest before you begin placing the leads, then you can lift her
breast up with the sheet as a barrier between your hand and her skin. Other suggestions are
that you ask the woman to lift the breast herself, or use the back of your hand, instead of your
palm, to lift the tissue.

The question always comes up as to whether V4 can be placed on top of the breast tissue
itself, or whether the breast must be lifted for placement of the electrode directly onto the
chest. As a general rule, you should place the sticky on the chest wall, not on the breast tissue,
as breast tissue tends not to stay in one place if the patient should move.
 3

5. Keep it Clean!
The patients skin needs to be clean, dry and free of lotions, powders, and sweat. This
takes on more meaning when you consider that the patients were seeing, many of whom are
having chest pain, may also be diaphoretic. Remember, also, that a lot of elderly patients have
very dry skin, especially on their lower extremities, and their dry flaky skin will prevent the
electrodes from sticking. Also, a lot of patients use lotion to counteract their dry skin, and that
lotion will interfere with the ability of the electrodes to stick.

Start by seeing if the electrodes will stick without any special treatment. If they do, then
youre good to go. If they dont, try cleansing the skin briefly with an alcohol prep pad. In
addition to removing some of the dry skin flakes and cleansing away the lotion, vigorously
rubbing with the alcohol pad for a few seconds (then letting it air dry) will abrade the skin
slightly and further enhance the contact surface.

Oh, and make sure youre not putting the stickies on over the patients nylon stockings!
Take a minute to remove them before applying the electrodes! (Dont laugh. It happens more
than you know!)

6. Gorrilla Syndrome
The patients skin also needs to be free of hair that interferes with electrode contact. This
doesnt mean you need to shave every man you do a 12 lead on. If the patients chest is hairy,
you may still be able to get away without shaving it (and the patient will be grateful a week
or so from now!) Unless there is an excessive amount of hair, or its very thick, long, or curly,
you might be able to just part it with your fingers and get the electrode to stick to the small
area of now-exposed skin.

If all else fails, you will need to shave the hair. Make sure you have already established
where the stickies need to go. And remember, your shaved area is like your signature if
you placed the electrodes incorrectly, all the world will know it because of the incorrectly-
placed little bald spots you left behind!

7. First Things First

Its often helpful, particularly with a fidgety patient, to put the chest leads on first. If you
put the limb leads on first and the patient moves his arms or crosses his legs while youre
putting the chest leads on, youll find yourself having to go back and reattach those electrodes
he knocked off in the process.

8. Look at the Patient, Not the Monitor!

Dont forget the basics. As with single lead monitoring, if you see a flat line, but your
patient is talking, you know the problem is the machine not the patient. If you get a flat line
but you know your patient is not in asystole, check your equipment. Begin at the patient and
check that you have attached a clip securely to each of the 10 electrodes you have placed on
the patient (one on each of the four limbs and six across the chest). A clip that has
inadvertently come off will usually be the cause of a lead not reading. If that doesnt solve the
 4

problem, then check your machine and make sure your lead pack wire is plugged securely
into the machine. Then check that each lead wire is plugged securely into the lead pack. Then
follow each lead to the patient and confirm that the clip is securely seated into the wire.

9. Provide support.
The key to getting an artifact-free cardiogram is a movement-free patient. If the patient
has to be using muscles to hold her head up, you will see artifact. Place the patient as close to
flat as she can tolerate. Provide a pillow and have the patient rest her head on that pillow. You
may need to reposition her in order to allow her head to rest comfortably. Some patients
might need more than one pillow to fill the space.

Similarly, make sure patients dont have to be using their own muscle strength to hold
their arms up. If the person is especially thin, she might be able to rest her arms comfortably
beside her body on the stretcher, but most of our patients spill over the stretcher sides. You
might ask the patient to sit on her hands in order to keep them on the stretcher without having
her have to use her muscle strength to keep them up. If that doesnt work, you may need to do
some creative strapping to include and fully support the entire length of the arms so the
patients muscles dont have to do any work.

10. Sit! Stay!

Ever notice how often elderly people are holding onto a tissue or handkerchief? Ever
notice how usually they are fidgeting with that tissue or handkerchief? Artifact! Ask the
patient if you can hold the tissue momentarily (or have the patient put it on his chest) during
the EKG acquisition. You will be amazed at how many times that simple change will take you
from an artifact-filled tracing to a clear one.

Many times when you instruct the patient to lie as still as he can, you still get artifact. A
quick look at the patient finds him with clenched fists and pointed toes, in his attempt to lie as
still as he can, just as you requested. Instructing him again to relax his muscles often falls on
deaf ears, as he thinks he already is relaxing! Try reaching down and gently shaking his arms
just a tiny bit, then doing the same with his legs; this will often help him release the tension
long enough that youll be able to get a better tracing.

Dont forget electromagnetic interference, either. If you find that your patient appears to
be lying still and relaxed, yet you still see artifact (especially 60-cycle interference), consider
the possibility that the problem is the electrical equipment around you, including lighting,
your portable radio, a cell phone, an automatic blood pressure machine, or even the wires
from the EKG machine itself. Try turning off and/or unplugging non-essential equipment,
uncrossing or repositioning leads going to the patient, or, if necessary, moving the patient to
another location to do the cardiogram.
 5

11. Whose Cardiogram Is It, Anyway?

If you want your cardiogram to be accepted by the emergency department staff and
placed into your patients chart, you must put some patient identification on it. Whether your
machine allows you to enter the name or whether you write it on the EKG by hand, be sure
that you identify it as your patients. You should document his name, date of birth and/or
MEMS state run sheet number, and the date and time of the tracing. Dont just leave it
unlabeled at the patients bedside when you drop the patient off, because that will quite likely
cause it to end up in the wastebasket later on because nobody can be certain which patient it
belongs to. Its also a good idea, if you have time, to mount it onto an 8 1/2 by 11 sheet of
paper so that it wont fall out of the record at some point because its a different size from
everything else.

12. Explain What Youre Doing While Youre Doing It.

Just because doing 12 leads has become old hat to you, it may not be such a routine
matter for the patient. And also remember that field 12 leads are a relatively new
phenomenon, and a lot of patients might not be expecting to have one done outside a hospital
or doctors office. Take the time to talk to the patient while you are applying the leads. Have
you ever had an electrocardiogram/EKG/12 lead done? It takes a picture of the electrical
activity going on in your chest, but it doesnt put any electricity into you. Im going to put
10 stickies on you, one on each of your arms and legs and six across your chest. The most
important thing you can do to help make this test come out accurate is to lie as still as
possible. For you, who have seen dozens of these done, there is no mystery, but your patient
will most likely appreciate the explanation.

Summary
Your prehospital EKG is the earliest cardiogram that the physician has on the patient. It
may be the only EKG obtained while the patient has pain, because while you did the 12 lead
you provided oxygen, put the patient at rest, and maybe gave nitro and morphine or fentanyl,
and the patient might be arriving at the hospital pain-free. Make sure that this earliest
cardiogram is the best quality it can be!

2
 6

005 by Jacky Vaniotis

 7

Overview

Electrocardiograph (EKG) artifacts are defined as EKG abnormalities, which are a

measurement of cardiac potentials on the body surface and are not related to electrical
activity of the heart.[1] As a result of artifacts, normal components of the EKG can be
distorted.[2] It is very important to recognize these artifacts, otherwise they can lead to
unnecessary testing and therapeutic interventions. In this chapter, we will present the
common causes and ways to characterize EKG artifacts.

Causes

EKG artifacts can be generated by internal and external causes[3].

Internal
These are physiological causes that could be due to:

Patient's motion: Does not allow electronic filtration (large swings,

usually by epidermal stretching).

o Tremors and shivering cause motion artifacts.

o Simple movements such as brushing and combing the hair can

produce EKG disturbances during ambulatory EKG monitoring.

Muscular activity: Allows electronic filtration (small spikes).[3]

External
These are non-physiological causes associated with other electrical devices attached to or
implanted (e.g. deep brain stimulator) in the body and includes the following[3]:

Electromagnetic interference:

o Power line electrical disturbances/ Light fixtures

o Electrocautery

o Electrical devices in the room

o Radiofrequency based commercial (e.g. mobile phones) products

Cable and electrode malfunction:

o Insufficient electrode gel

o Misplaced leads
 8

o Inappropriate filter settings

o Broken wires

o Loose connections

o Accumulation of static energy

Medical equipments: In operation theatres and intensive care unit

various equipments can affect EKG monitoring system (e.g. electrodes,
leads, amplifier, filters).[4][5][6]

Medical equipment related EKG artifacts

Type of equipment Artifact

Atrial or ventricular extrasystoles,

IVAC intravenous infusion controller
pseudowaves (QRS)

Uninterpretable tracing, non-

Cardiopulmonary bypass pump
specific

Pressure-controlled irrigation pump Atrial flutter

COBE Prisma System for continuous

Atrial flutter
venovenous hemofiltration

Flexible bronchoscope Atrial fibrillation

Deep brain stimulator Uninterpretable tracing

Straight shot microdebrider (nasal

Ventricular tachycardia
endoscopy)

Pseudowaves (P), premature atrial

Intra-aortic balloon pump
contraction

Somatosensory evoked potential

Supraventricular tachycardia
monitoring units

High-frequency
 9

Somatosensory evoked potential

Supraventricular tachycardia
monitoring units

High-frequency oscillatory Atrial flutter, atrial fibrillation, ventricular

ventilation tachycardia

Ventricular tachycardia, ventricular

Intraoperative high-field MRI
fibrillation, non-specific

Transcutaneous electrical nerve Spikes, runaway pacemaker, ventricular

stimulator fibrillation, non-specific

Peripheral nerve stimulator Spikes, loss of pacemaker spikes

The table includes data from references[5][7]

Identification

Artifacts can distort individual or all components (P, QRS, T waves and PR and ST segments)
on the EKG. Most of the time, they are easily identifiable and neglected as they do not
resemble any specific pattern. It is important to differentiate these artifactual changes from
genuine changes to prevent misdiagnosis. If ST segments are affected by artifacts, either ST
segment depression or elevation can occur on the EKG. These changes can be misinterpreted
as myocardial ischemia or infarction.

Differentiating an Artifact from Ventricular tachycardia

Sometimes, EKG changes may mimic specific arrhythmias like ventricular tachycardia and
atrial flutter or fibrillation.[8] It is important to differentiate these, as misdiagnosis can lead to
inadvertent use of medications and procedures in such a patient[9][10].

Characteristics that can help in differentiate an artifact from ventricular

tachycardia include[9]:

o Absence of hemodynamic deterioration during the event.

o Normal QRS complexes within the artifact.

o An unstable baseline on the EKG before the event, after the event,
or both.

o Association with bodily movement.

Huang et al[10] also described 3 signs that may help in differentiating a

tremor-induced pseudo-ventricular tachycardia from true ventricular
tachycardia. Presence of any of these signs is suggestive of pseudo-
ventricular tachycardia:
 10

o "Sinus" sign: One of the frontal leads (I, II and III) may present with
sinus rhythm showing normal P, QRS, and T waves. The reason is
that one of the upper limbs may be free off tremor.

o "Spike" sign: Presence of regular or irregular tiny spikes among

wide-QRS complexes.

o "Notch" sign: Notches superimposed in the wide-QRS-like complex

artifact, coinciding with the cycle length when sinus rhythm was
recorded.

Electrode misplacement
Electrode misplacements are a common artifact that can mimic life-threatening arrhythmias.
Early identification and replacement of electrodes can help in avoiding unnecessary therapies.
An algorithm has been described previously[3], which may help in recognizing these artifacts.

REVERSE mnemonic: Approach to EKG artifacts[3]

EKG findings Explanation

R R wave is positive in lead aVR (P wave also Reversal of left arm and right
positive) arm electrodes

E Extreme axis deviation: QRS axis between Reversal of left arm and right
-90 and +180 arm electrodes

V Very low (<0.1 mV) voltage in an isolated Reversal of right leg and left
limb lead arm or right arm electrodes

E Exchanged amplitude of P waves (P wave in Reversal of left arm and left leg
lead I > lead II) electrodes

R R wave abnormal progression in precordial Reversal of precordial

lead (pre-dominal R in V1 and S in V6) electrodes (V1 through V6)

S Suspect dextrocardia (negative P waves in Reversal of left arm and right

lead I) arm electrodes
 11

E Eliminate noise and interference (artifact

mimicking tachycardias or ST-T changes

Table adapted from Baranchul et al's work[3]: Crit Care Nurse 2009;29:67-73 doi:
10.4037/ccn2009607

Other Common Artifacts

Electrodes on the torso: Placement of the electrodes on torso may lead

to a change in vectors and produce pseudo-Q waves and pseudo-ST
segment elevation, mimicking myocardial infarction.[3]

Telemetry interference: Superimposition of telemetry electrodes over

the EKG electrodes or vice versa may cause ST segment deviation due to
electromagnetic interference.[3]

Loose wire: Straight line may resemble systole and a wavy line may
resemble fibrillation. However, it will be limited to one or two leads only.

Tall T wave: A tall T wave may be mistaken for an R wave and the digital
heart rate would be higher than the actual pulse rate.

Lead placement: Obscuring of P waves may resemble a heart block.

Motion artifact: Chest percussions or physiotherapy may mimic

ventricular fibrillation.

Consequences

Apart from the poor quality of EKG, artifacts can cause serious consequences particularly
when they mimic genuine changes. If EKG artifacts are not recognized by physician,
anesthesiologist or intensivist unneccasry diagnostic and therapeutic measures could be
taken. Such actions may subject patients to invasive investigations or they may receive
unnecessary medications like antiarrythmics.

Correction

Attention to basic principles such as proper electrodes placement and lead

connections (as mentioned above) is required during EKG monitoring.

Well designed and maintained EKG measurement devices can withstand

routine internal or external electrical and motion-related disturbances.
However, it is not always possible to eliminate artifacts completely.

It is essential that physicians keep high vigilance and interpret EKG

keeping artifacts in their differential diagnosis list.

Examples of Artifacts
 12

The gallery of images below shows a variety of EKG artifacts that are due to tremor,
movement, movement disorders and electrical interference. These artifacts should not be
confused with an abnormality in the patient's electrocardiogram. Atrial fibrillation can be
confused with these artifacts.

Increasing movement artifacts in a Parkinson patient.

Baseline drift. The amplifier in the ECG machine has to re-find the 'mean'. This
often occurs right after lead connection and after electric cardioversion.
 13

Cardioversion from atrial fibrillation to sinus rhythm, with clear baseline drift.

Technical Problems

Jump to: navigation, search

Author(s) J.S.S.G. de Jong

Moderator J.S.S.G. de Jong

Supervisor

some notes about authorship

Contents

1 Lead reversals

2 Artifacts

3 Filter settings

4 References

Lead reversals
 14

A Normal ECG

right arm - right leg reversal

left arm - left leg reversal

left leg - right leg reversal.

v3 - v2 reversal
 15

left - right reversal

Lead switches are a common mistake when ECGs are made and can lead to wrong diagnoses.
Common mistakes are:

Left-right arm reversals lead to a negative complex in lead I with a

negative P wave in lead I. They are one of the most common causes of
right axis deviation on the ECG!

Arm-foot switches lead to a very small or 'far field' signal in leads II or

III.

Chest lead reversals lead to inappropriate R wave progression

(increase-decrease-increase) and are often easily recognized.

Therefore any right axis or small signal in an extremity lead should be reason enough to
check lead positioning. A previous ECG can be very helpful.

More specific patterns with every lead reversal:

right and left arm electrodes:

o inversion of lead I

o reversal of leads II and III

o reversal of leads aVR and aVL

right leg and right arm:

o diminished signal in lead II

left arm and left leg:

o reversal of leads I and II

o reversal of leads aVL and aVF

o inversion of lead III

right arm and left leg:

 16

o inversion of leads I, II and III

o reversal of leads aVR and aVF

It is possible to distinguish lead reversal and dextrocardia by watching the precordial leads.
Dextrocardia will not show any R wave progression in leads V1-V6, whereas lead reversal
will.

Right and left arm lead reversal can be distinguished from the (much rarer)
dextrocardia by examination of the precordial R wave progression.

Right arm and left leg lead reversal. Lead II now measures the signal between the left
and right leg, which is remote from the heart.

A patient with dextrocardia (and previous inferior myocardial infarction)

Another patient with dextrocardia

Artifacts

Artifacts (disturbances) can have many causes. Common causes are:

Movement

Electrical interference

Filter settings
 17

Although not a technical problem, filter settings influence the interpretation of the ECG.[1]

Filter settings can influence the interpretation of ST elevation as these examples

show. On the left side an ECG with normal settigns (0.01-40Hz), on the right side
a rhythm strip from the same patient with a different high-pass filter setting
(0.32-40Hz). Also, the P wave morphology is different between the two ECGs.

To reduce electrical interference ECG machine use two filters:

A high-pass filter reduces low frequency noise. This filter reduces base line
drift on the ECG.

A low-pass filter reduces high frequency noise, such as produces by chest

and extremity muscles and electrical interference from the power grid.

Depending on the purpose of the ECG these filters can be adjusted.

In the monitor mode the high-pass filter can be set higher at 0.5-1.0 Hz
and the low-pass filter on 40 Hz. This is the strongest filter setting (only a
narrow frequency range is passed by the filter). This setting is especially
useful for rhythm monitoring where noise can be distracting and ST
segment interpretation is not very important. In this mode,
pacemakerspikes are sometimes invisible while filtered out.

In the diagnostic mode the high-pass filter is set at 0.05 Hz and the low-
pass filter at 40, 100 or 150 Hz. This improves the diagnostic accuracy of
the ST semgent. On the downside a base line drift occurs more easily.

 18

Movement artifacts

Increasing movement artifacts in a Parkinson's patient. The patient was in sinus

rhythm (which doesn't show on this short recording)!

Baseline drift. The amplifier in the ECG machine has to re-find the 'mean'. This often
occurs right after lead connection and after electric cardioversion.

Cardioversion from atrial fibrillation to sinus rhythm, with clear baseline drift.

Electrical interference from a nearby electrical appliance. A typical example is a 100

Hz background distortion from fluorescent lights. Not to be confused with atrial
fibrillation.
 19

Another example of an artifact caused by an electrical appliance. The patients rhythm

is regular. This strip shows 10 QRS complexes.

An artifact that was originally diagnosed as a VT

References

1 Garca-Niebla J, Llontop-Garca P, Valle-Racero JI, Serra-Autonell G,

Batchvarov VN, and de Luna AB. Technical mistakes during the acquisition
of the electrocardiogram. Ann Noninvasive Electrocardiol 2009 Oct; 14(4)
389-403. doi:10.1111/j.1542-474X.2009.00328.x pmid:19804517. PubMed