ECG/EKG lead placement

Electrocardiography (ECG) is a technique that detects the electrical signals from a patient's heart and then records it on to a strip of paper. An ECG is a basic investigation that all junior doctors have to be comfortable at doing. It allows the clinician to see the electrical activity of the heart. It is a simple and invaluable tool to help make a diagnosis. It is important to know exactly where the leads are placed as incorrect lead placement could result in a poor trace that could miss underlying cardiac pathology such as a myocardial infarction.

Indications

  • Chest pain

  • SOB

  • Collapse

  • Palpitations

  • Pre-op

  • Electrolyte abnormalities

  • Many more… if in doubt just do one!

Contraindication

  • Lack of consent

Wash hands

Wash your hands using the Ayliffe technique

Introduce yourself

Introduce yourself and give your name and grade

  “Hi, my name is Jack Dawson and I am a 4th year medical student”

Check patient details

Clarify patient's identity by confirming name and asking for their DOB

Describe procedure

Explain what  you will be performing and what it involves

“Today I will be taking a trace of your heart. This will involve placing stickers on various parts of your chest and limbs and attaching leads to them. In some areas we may need to shave hair to ensure that the stickers remain attached.”

Gain verbal consent

“Would this be ok with you?”

Offer a chaperone

Equipment

  • 12- lead ECG machine

  • Adhesive ECG stickers

  • Adequate ECG paper

  • Razor – may be required.

Pre­Procedure

  • Position patient at 45 degree angle
  • Gather equipment

Procedure

Limb lead Placement

Colour

Right wrist

Red

Left wrist

Yellow

Left ankle

Green

Right ankle

Black

  • Remember ‘Ride Your Green Bike’ in a clock wise manner from the right wrist.
  • Place ECG chest  stickers as shown in video above and attach leads
  • Attach limb stickers and leads, ensure they are attached to bony prominence at wrist and ankle to ensure a good trace
  • Turn machine on and enter patient details
  • Explain the importance of relaxing to patient for the procedure as moving causes artifacts
  • Press record and review ECG once printed

Thank patient

Let the patient know you have finished examining them and thank them for their time. Be courteous and offer them help to get redressed.

“That’s the end of the procedure. Thank you for your time. Would you like any help  getting dressed?”

Accurate documentation

Ensure that you have written patient details on the ECG, as well as signing it to show it has been reviewed. Thereafter, write in the patient notes summary of findings and management plan.

Complications

Allergic reaction to ECG stickers

Top Tips

  • ECG stickers don’t stick well to hair, consider shaving patches for better contact – seek consent first!
  • Do not rely solely on the ECG machine’s interpretation for diagnosis, these can be sometimes misleading.
  • If the trace is poor it may be due to poor ECG sticker contact or miss placement. If this persists and the patient is keeping still then consider changing the lead set.
  • If the stickers aren’t attaching to the patient, wipe away the sweat and try again.
  • Always document patient details on ECGs and the time – this allows you to look back at serial ECGs and  stops them from getting lost.