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12 LEAD ELECTROCARDIOGRAM (ECG) PLACEMENT

MODULE DESCRIPTION

This module presents the proper procedure in performing electrocardiogram (ECG). It will
particularly emphasize the proper placement of electrodes in the body.

COURSE LEARNING OUTCOMES

 Apply guidelines and principles of evidence-based practice in the delivery

of care.
 Practice nursing in accordance with existing laws, legal, ethical and moral principles and
standards.
 Communicate effectively in speaking, writing and presenting using culturally-
appropriate language.
 Document to include reporting up-to-date client care accurately and comprehensively.
Work effectively in collaboration with inter-,intra-, and multi-disciplinary and multi-
cultural teams.

PRE-TEST

Name the four sites of origin of impulses that are used to name dysrhythmias.
1.________________________
2.________________________
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3.________________________
4.________________________

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TOPIC

What is an ECG?
An ECG stands for electrocardiogram. It is a tool used to detect a wide range of heart dysrhythmias using
waveforms on a monitor. It is used by healthcare providers regularly both in the hospital and by EMS.

ECG is recommended if a person is experiencing symptoms such as:

 chest pain
 shortness of breath
 dizziness
 fainting, or 
 fast or irregular heartbeats (palpitations). 

The three major types of ECG are: 

 resting ECG – you lie down for this type of ECG. No movement is allowed during the test, as
electrical impulses generated by other muscles may interfere with those generated by your heart. This
type of ECG usually takes 5 to 10 minutes
 ambulatory ECG – if you have an ambulatory or Holter ECG you wear a portable recording
device for at least 24 hours. You are free to move around normally while the monitor is attached. This
type of ECG is used for people whose symptoms are intermittent (stop-start) and may not show up on a
resting ECG, and for people recovering from heart attack to ensure that their heart is functioning
properly. You record your symptoms in a diary, and note when they occur so that your own experience
can be compared with the ECG
 cardiac stress test – this test is used to record your ECG while you ride on an exercise bike or
walk on a treadmill. This type of ECG takes about 15 to 30 minutes to complete.

General consideration in performing ECG procedure

 There is no need to restrict food or drink before having an ECG test. Always let your doctor
know what medications you are taking before you have an ECG, and if you have any allergies to
adhesive tapes that may be used to attach electrodes.
 When you go for an ECG test, you will need to remove your upper clothing so that electrodes
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can be attached to your chest and limbs. (For women, wearing a separate top with trousers or a
skirt can allow easy access to the chest.) The selected sites are shaved, if necessary.
 Electrodes (sensors) are attached to the chest, arms and legs with suction cups or sticky gel.
These electrodes detect the electrical currents generated by the heart – these are measured and
recorded by the electrocardiograph. 

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 When the procedure is completed, the electrodes are removed. An ECG is completely painless
and non-invasive, as the skin is not penetrated. 

The doctor can interpret the results of your ECG straight away based on your medical history, symptoms and
clinical examination

What is ECG Interpretation?

An electrocardiogram or ECG, records electrical activity in the heart. An ECG machine records these
electrical signals across multiple heart beats and produces an ECG strip that is interpreted by a
healthcare professional.

How Electrocardiograms Work - ECG Strips

To briefly summarize the components of a normal ECG tracings, it consist of waveform components
which indicate electrical events during one heart beat. These waveforms are labeled P, Q, R, S, T and U.

P wave is the first short upward movement of the ECG tracing. It indicates that the atria are contracting,
pumping blood into the ventricles.

The QRS complex, normally beginning with a downward deflection, Q; a larger upwards deflection, a
peak (R); and then a downwards S wave. The QRS complex represents ventricular depolarization and
contraction.

The PR interval indicates the transit time for the electrical signal to travel from the sinus node to the
ventricles.

T wave is normally a modest upwards waveform representing ventricular repolarization.

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4-Lead Placement
Before we can get to placing our precordial leads, we need to know where our 4-lead goes. Ever heard
4-leads referred to as “limb leads”? There’s a reason for that. These leads are not suppose to go
anywhere on the torso. It’s not as big of a deal if you’re only doing a 4-lead, but doing so when you’re
going to put the precordial leads on will alter the morphology of your EKG.
Limb leads can be placed on any part of the patient’s respective limbs. Just make sure the leads are
symmetrical. For example, don’t put one lead on the left shoulder and the other lead on the right
forearm. I’ve heard of one local doctor that preferred all 4 leads to be placed relatively equal distances
distally. For example, if you put leads on the wrists, then leads should also go on the ankles. I haven’t
found anything to back that, but that’s at least one professional’s theory.

The 12-lead ECG electrode placement is essential for paramedics and EMTs in both prehospital and
hospital setting as incorrect placement can lead to false diagnosis of infarction or negatively change the
EKG.

Proper 12-Lead ECG Placement

Now that we have our 4-leads straight, let’s talk about where your precordial leads will go. Everyone
slaps [Date]
them on below the breast and sometimes below the entire rib cage. That is completely
unacceptable! Below is a bullet point list for each lead, a description of where they go, and the order
they should be applied.

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ELECTRODE PLACEMENT

V1 4th Intercostal space to the right of the sternum

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 right ankle and below the torso

RA Anywhere between the right shoulder and the wrist

LL Anywhere above the left ankle and below the torso

LA Anywhere between the left shoulder and the wrist

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Aside from a 12-lead ECG placement, there’s something known as a 15-lead placement which includes
placing leads V4-V6 on the posterior side of the patient below their left scapula (see below). When
viewing the EKG strip, V4-V6 on the strip will be referred to as V-13-15. To clarify, leads will equal:
V4=V7, V5=V8, and V6=V9.

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Lastly, a right sided 12-lead ECG placement allows you to detect a right sided infarct. At a minimum, lead
V4 should be placed on the 5th intercostal, mid-clavicular (exact opposite of the regular left side
placement) if an inferior infarct was originally seen in leads II, III, and AVF.

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These give you more views of the heart and can help inform your treatment plans. For instance, you
never want to give nitroglycerin if you see an inferior infarct until after performing a right-sided EKG.
You can view these and other helpful diagrams.

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Long-term outlook – heart problems diagnosed by ECG

The results of your ECG will determine what treatment you need, if any. 

Some of the various heart problems that can be diagnosed by ECG include: 

 enlargement of the heart

 congenital heart defects involving the conducting (electrical) system
 abnormal rhythm (arrhythmia) – rapid, slow or irregular heart beats 
 damage to the heart such as when one of the heart’s arteries is blocked (coronary occlusion)
 poor blood supply to the heart
 abnormal position of the heart
 heart inflammation – pericarditis or myocarditis
 cardiac arrest during emergency room or intensive care monitoring 
 disturbances of the heart’s conducting system
 imbalances in the blood chemicals (electrolytes) that control heart activity
 previous heart attacks.

A person with heart disease may have a normal ECG result if the condition does not cause a disturbance
in the electrical activity of the heart. Other diagnostic methods may be recommended if heart disease is
suspected.

Treatment for a heart condition depends on the diagnosed condition but may include: 

 medication
 surgery
 dietary changes
 quitting smoking
 regular exercise.

For example, the following conditions diagnosed by ECG may require the treatment specified:

 disturbances in heart rhythm – medication or surgery (such as installing an artificial pacemaker)

 coronary artery disease or heart attack – medications, stenting, quitting cigarettes, dietary
changes and coronary artery bypass surgery
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 high blood pressure – dietary changes, regular exercise and medications .

Several symptoms can indicate that you may need an EKG to determine if your heart is functioning
normally. Seek emergency medical attention if you experience:

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 chest pain or discomfort

 difficulty breathing

 heart palpitations or feeling your heart beating oddly

 the feeling that you might pass out

 racing heart

 the feeling that your chest is being squeezed

 sudden weakness

What an abnormal EKG indicates

Because an EKG measures so many different aspects of the heart’s function, abnormal results can signify
several issues. These include:

Defects or abnormalities in the heart’s shape and size: An abnormal EKG can signal that one or more
aspects of the heart’s walls are larger than another. This can signal that the heart is working harder than
normal to pump blood.

Electrolyte imbalances: Electrolytes are electricity-conducting particles in the body that help keep the
heart muscle beating in rhythm. Potassium, calcium, and magnesium are electrolytes. If your
electrolytes are imbalanced, you may have an abnormal EKG reading.

Heart attack or ischemia: During a heart attack, blood flow in the heart is affected and heart tissue can
begin to lose oxygen and die. This tissue will not conduct electricity as well, which can cause an
abnormal EKG. Ischemia, or lack of blood flow, may also cause an abnormal EKG.
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Heart rate abnormalities: A typical human heart rate is between 60 and 100 beats per minute (bpm). An
EKG can determine if the heart is beating too fast or too slow.

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Heart rhythm abnormalities: A heart typically beats in a steady rhythm. An EKG can reveal if the heart is
beating out of rhythm or sequence.

Medication side effects: Taking certain medications can impact a heart’s rate and rhythm. Sometimes,
medications given to improve the heart’s rhythm can have the reverse effect and cause arrhythmias.
Examples of medications that affect heart rhythm include beta-blockers, sodium channel blockers,
and calcium channel blockers.

POST TEST

1.Why Is 12-Lead ECG Placement Important?

REFERENCE

 Brady WJ, Truwit JD. Critical Decisions in Emergency and Acute Care Electrocardiography
 Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice: Adult and Pediatric
 Wagner GS. Marriott’s Practical Electrocardiography 12e
 Chan TC. ECG in Emergency Medicine and Acute Care
 Rawshani A. Clinical ECG Interpretation
 [Date]
Mattu A. ECG’s for the Emergency Physician
 Hampton JR. The ECG In Practice, 6e

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REFERENCE

Start here

REFLECTION

Start here

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