hest Leads

There are 10 wires on an ECG machine that are connected to specific parts of the body. These
wires break down into 2 groups:
1. 6 chest leads
2. 4 limb or peripheral leads (one of these is "neutral")
The 6 chest leads are positioned as below:
Image: Positioning of the 6 chest leads

The 6 leads are labelled as "V" leads and numbered V1 to V6. They are positioned in specific
positions on the rib cage. To position then accurately it is important to be able to identify the
"angle of Louis", or "sternal angle".
To find it on yourself, place your fingers gently at the base of your throat in a central position
and move your fingers downward until you can feel the top of the sternum, or rib cage. From this
position, continue to move your fingers downward until you feel a boney lump. This is the "angle
of Louis".
The angle of Louis is most easily found when the patient is lying down as the surrounding tissue
is tighter against the rib cage.
From the angle of Louis, move your fingers to the right and you will feel a gap between the ribs.
This gap is the 2nd Intercostal space. From this position, run your fingers downward across the
next rib, and the next one. The space you are in is the 4th intercostal space. Where this space
meets the sternum is the position for V1.

Go back to the "angle of Louis" and move into the 2nd intercostal space on the left. Move down
over the next 2 ribs and you have found the 4th intercostal space. Where this space meets the
sternum is the position for V2.
From this position, slide your fingers downward over the next rib and you are in the 5th
intercostal space . Now look at the chest and identify the left clavicle, a bone that runs from the
left shoulder to the top of the sternum. The position for V4 is in the 5th intercostal space , in line
with the middle of the clavicle (mid-clavicular). V3 sits midway between V2 and V4.
Follow the 5th intercostal space to the left until your fingers are immediately below the beginning
of the axilla, or under-arm area. This is the position for V5.
Follow this line of the 5th intercostal space a little further until you are immediately below the
centre point of the axilla, (mid-axilla). This is the position for V6.
Now look at the picture below showing the position of the heart in relation to the rib-cage and
you get an idea as to which areas are being looked at by these leads.

Electrocardiography (ECG)
BY DAISY JANE ANTIPUESTO RN MN SEPTEMBER 8, 2010

Electrocardiography is the
most commonly used test for
evaluating cardiac status,
graphically records the electrical
current (electrical potential)
generated by the heart. This
current radiates from the heart in
all directions and, on reaching
the skin, is measured by
electrodes connected to an
amplier and strip chart recorder.
The standard resting ECG uses
five electrodes to measure the
electrical potential from 12 different leads; the standard limb leads (I,II,III), the
augmented limb leads (aVf, aVL, and aVr), and the precordial, or chest, leads (V1
through V6).

ECG tracings normally consist of three identifiable waveforms: the P wave, the QRS
complex, and the T wave. The P wave depicts atrial depolarization; the QRS complex,
ventricular depolarization; and the T wave, ventricular repolarization.
Computerized ECG machines use small electrode tabs that peel off a sheet and adhere
to the patients skin. The entire ECG tracing is displayed on a screen so abnormalities
can be corrected before printing; then its printed on one sheet of paper. Electrode tabs
can remain on the patients chest, arms, and legs to provide continuous lead placement
for serial ECG studies.
Purpose of Electrocardiography (ECG)
To help identify primary conduction abnormalities, cardiac arrhythmias, cardiac
hypertrophy, pericarditis, electrolyte imbalances, myocardial ischemia, and the
site and extent of myocardial infarction.
To monitor recovery from an MI.
To evaluate the effectiveness of cardiac medication.
To assess pacemaker performance
To determine effectiveness of thrombolytic therapy and the resolution of STsegment depression or elevation and T-wave changes.
Electrocardiography (ECG) Procedure
Patient Preparation for Electrocardiography (ECG)
1. Explain to the patient the need to lie still, relax, and breathe normally during the
procedure.
2. Note current cardiac drug therapy on the test request form as well as any other
pertinent clinical information, such as chest pain or pacemaker.
3. Explain that the test is painless and takes 5 to 10 minutes.
Implementation
1. Place the patient in a supine or semi-Fowlers position.
2. Expose the chest, ankles, and wrists.
3. Place electrodes on the inner aspect of the wrists, on the medical aspect of the
lower legs, and on the chest.
4. After all electrodes are in place, connect the lead wires.
5. Press the START button and input any required information.
6. Make sure that all leads are represented in the tracing. If not, determine which
electrode has come loose, reattach it, and restart the tracing.

7. All recording and other nearby electrical equipment should be properly grounded.
8. Make sure that the electrodes are firmly attached.
Nursing Interventions
1. Disconnect the equipment, remove the electrodes, and remove the gel with a
moist cloth towel.
2. If the patient is having recurrent chest pain or if serial ECGs are ordered, leave
the electrode patches in place.
Interpretations
Normal Results
1. P wave that doesnt exceed 2.5 mm (0.25 mV) in height or last longer than 0.12
second.
2. PR interval (includes the P wave plus the PR segment) persisting for 0.12 to 0.2
second for heart rates above 60 beats/min.
3. QT interval that varies with the heart rate and lasts 0.4 to 0.52 second for heart
rates above 60 beats/min.
4. Voltage of the R wave leads V1 through V6 that doesnt exceed 27 mm.
5. Total QRS complex lasting 0.06 to 0.1 second.
Abnormal Results
1. Myocardial infarction (MI), right or left ventricular hypertrophy, arrhythmias,
right or left bundle-branch block, ischemia, conduction defects or pericarditis, and
electrolyte abnormalities.
2. Abnormal wave forms during angina episodes or during exercise.
Precautions
The recording equipment and other nearby electrical equipment should be
properly grounded to prevent electrical interference.
Double-check color codes and lead markings to be sure connectors march.
Make sure that the electrodes are firmly attached, and reattached them if loose
skin contact is suspended. Dont use cables that are broken, frayed, or bare.
Interfering Factors
Improper lead placement.
Complications
Skin sensitivity to the electrodes.

12-Lead ECG Placement

APRIL 27, 2014 BY EMTRESOURCE.COM 73 COMMENTS

The 12-lead ECG is a vital tool for EMTs and paramedics in both the prehospital and
hospital setting. It is extremely important to know the exact placement of each electrode
on the patient. Incorrect placement can lead to a false diagnosis of infarction or negative
changes on the ECG.

Electrode Placement

ELECTRODE

V1

PLACEMENT

4th Intercostal space to the right of the sternum

ELECTRODE

PLACEMENT

V2

4th Intercostal space to the left of the sternum

V3

Midway between V2 and V4

V4

5th Intercostal space at the midclavicular line

V5

Anterior axillary line at the same level as V4

V6

Midaxillary line at the same level as V4 and V5

RL

Anywhere above the ankle and below the torso

RA

Anywhere between the shoulder and the elbow

LL

Anywhere above the ankle and below the torso

ELECTRODE

LA

PLACEMENT

Anywhere between the shoulder and the elbow

Electrode Misplacement

Up to 50% of cases have the V1 and V2 electrodes in a more superior location, which can
mimic an anterior MI and cause T wave inversion.

Up to 33% of cases have the precordial electrodes (V1-V6) inferiorly or laterally

misplaced, which can alter the amplitude and lead to a misdiagnosis.

Electrode Reversal

RA/LA Reversal: Lead I is inverted, Lead II and III are reversed, aVR and aVL are
reversed

RA/RL Reversal: Lead II shows isolated asystole, aVF and aVR are identical

LA/LL Reversal: Lead III is inverted, aVL and aVF are reversed

Lead Groups
The ECG leads are grouped into two electrical planes. The frontal leads (Lead I-III,
aVR-F) view the heart from a vertical plane, while the transverse leads (V1-V6) view the
heart from a horizontal plane.

LEAD

(-) ELECTRODE

(+) ELECTRODE

VIEW OF HEART

Lead I

RA

LA

Lateral

Lead II

RA

LL

Inferior

Lead III

LA

LL

Inferior

aVR

LA + LL

RA

None

aVL

RA + LL

LA

Lateral

LEAD

(-) ELECTRODE

(+) ELECTRODE

VIEW OF HEART

aVF

RA + LA

LL

Inferior

V1

Septal

V2

Septal

V3

Anterior

V4

Anterior

V5

Lateral

V6

Lateral

12-Lead Explained
One of the most common questions regarding a 12-lead ECG is why there are only 10
electrodes. Its important to fully understand what the term lead actually means. A lead
is a view of the electrical activity of the heart from a particular angle across the body.

Think of a lead as a picture of the heart and the 10 electrodes give you 12 pictures. In
other words, a lead is a picture that is captured by a group of electrodes.

Reducing Artifact
The hearts electrical signal is very small and unfortunately this can be combined with
other signals of similar frequency to create artifact. Its not uncommon for 12-lead
ECGs to have some form of artifact; however, its important to try to reduce any
interference to ensure an accurate ECG. Below is a list of guidelines that will help
reduce artifact when performing ECGs.
Patient Positioning

Place the patient in a supine or semi-Fowlers position. If the patient cannot tolerate being
flat, you can do the ECG in a more upright position.

Instruct the patient to place their arms down by their side and to relax their shoulders.

Make sure the patients legs are uncrossed.

Move any electrical devices, such as cell phones, away from the patient as they may
interfere with the machine.

Skin Preparation

Dry the skin if its moist or diaphoretic.

Shave any hair that interferes with electrode placement. This will ensure a better
electrode contact with the skin.

Rub an alcohol prep pad or benzoin tincture on the skin to remove any oils and help with
electrode adhesion.

Electrode Application

Check the electrodes to make sure the gel is still moist.

Do not place the electrodes over bones.

Do not place the electrodes over areas where there is a lot of muscle movement.