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com: ECG Electrodes, Cables, & Leads

Electrodes, leads &

wires
A practical guide to ecg
monitoring and recording.
Updated 8th January 2008

A striking example of what can happen if you change the limb

electrode positions.

Several A&E nurses have told me of carefully placed chest electrodes

being removed by ccu staff, and replaced with chest electrodes in the
wrong positions. This may be because ccu are using the EASI™ 12
lead monitoring system - see below.

An excellent paper "Resting 12-Lead ECG Electrode Placement and

Associated Problems" has been brought to my attention. Available
from the Society for Cardiological Science and Technology web site. It
contains many example ecg's to help you spot incorrect electrode
placement.

Settling arguments
The most frequent question I get asked, in or out of the classroom, is
"Where should the electrodes be placed". But before I answer, let's
consider some basic principles, and see how the answers depend on a
number of factors.

OK, if you don't want to read it all, you can go straight to the most
common question "where to put the limb electrodes for a 12 lead ecg".

Always remember that when someone insists on doing things a certain

way, they can usually find that someone somewhere has written a
paper on it. I've had to suffer working with anaesthetists who insist
that a particular electrode must go in a particular position. At the time
I knew it did not matter, but I always preferred a quiet life in theatre,
so I just let them get on with it. ;-)

Leads and wires - why 6+4=12

Between the patient and the ecg machine is a patient cable, and this is
divided into a number of different coloured wires, maybe 3, 4 or 5 for
monitoring purposes, or 10 wires for a 12 lead ecg.

A lead is a view of the electrical activity of the heart from a particular

angle across the body, obtained by using different combinations of
these wires. Leads are pictures, you cannot point to one of the wires
or electrodes on the patient and say "this is lead so and so", to say
this you would have to point to a "group" of wires.
To obtain a 12 lead ecg you would have 4 wires attached to each of
the limbs, and six wires placed around the chest, 10 wires in total but
you get 12 "leads" or pictures. In a similar way a combination lock
may have 50 numbers but it has thousands of possible combinations.

Leads and wires (part 2) - how 5 wires can

give you 12 leads
Philips Medical Systems produce the EASI™ 12 lead system.
This uses 5 electrodes and "derives" the 12 leads from these. The
electrode positions are:

• Upper sternum (just below sternal angle)

• Lower sternum (fifth intercostal space)
• Right midaxillary line (fifth intercostal space)
• Left midaxillary line (fifth intercostal space)
• Ground (can be anywhere)

But let's now leave such specialised systems and go back to basics.
How the standard 12 leads "look" at the
heart
To measure any electrical activity you need at least two electrodes (a
positive and a negative) in order to form an electrical circuit. If using
defibrillator paddles to obtain a trace, you are using this principle. So
we have one electrode "looking" between itself and the other
electrode. By changing the position of either of these electrodes we
alter the angle at which we are viewing any activity.

Important point, no matter which lead is being used to "look" at the

heart, the electrode doing the looking is always a single electrode. But
the "other" electrode could be a single electrode or a number of other
electrodes joined together (electrically) to form a reference point.

The six chest leads are simple enough, each of the six chest electrodes
looks from that point on the chest wall, the six wires give you six
different views. The "other" electrode in each of these views, is created
by the machine "joining together" the limb connections, thus making
the centre of the body the reference point.

The six limb leads work differently, leads I, II and III are each making
use of a pair of electrodes, with one electrode looking between itself
and the other as shown below. Leads aVR, aVL and aVF each make use
of all the limb connections to the patient, but again one single
electrode is doing the looking (relative to the others).

When you try to think of how the limb leads look at the heart imagine
the views as taken from positions around a clock face (as facing the
patient).

With electrodes on the right arm (red), left arm (yellow) and
left leg (green)

• Lead I uses red and yellow, yellow is looking from 3 o'clock.

• Lead II uses red and green, green is looking from 5 o'clock.
• Lead III uses yellow and green, green is looking from 7 o'clock.
• Lead aVR is looking from the red wire, across to between yellow
and green, 10 o'clock.
• Lead aVL is looking from the yellow wire, across to between red
and green, 2 o'clock.
• Lead aVF is looking from the green wire, across to between
yellow and red, 6 o'clock.
When considering all the above leads, and the wires that are involved.
Notice that you must have the limb electrodes connected to the patient
in order to record the six chest leads. But you do not need the chest
electrodes connected in order to record the limb leads.

My thanks to Dr Bruce Graham of Charles Sturt University NSW

Australia for contributing suggestions concerning the limb and chest
leads.

Different coloured wires

It's important that you know if you're using a European or American
patient cable for monitoring because the colours of the wires will differ
as shown below.

All references on this page are based on the european (IEC) cable
colours.

Monitoring cable connections

Europe Connect to: U.S.A.

Red Right Arm White

Yellow Left Arm Black
Green Left Leg Red
Black Right Leg Green
White Chest Brown
Individual chest leads
White / Red C1 / V1 Brown / Red
White / Yellow C2 / V2 Brown / Yellow
White / Green C3 / V3 Brown / Green
White / Brown C4 / V4 Brown / Blue
White / Black C5 / V5 Brown / Orange
White / Violet C6 / V6 Brown / Purple

Different numbers of wires

A 3 wire cable (red, yellow, green) or (red, yellow, black) can only give
you a choice of limb leads.

A 4 wire cable (red, yellow, green, black) can only give you a choice of
limb leads.

A 5 wire cable (red, yellow, green, black, white) will give you limb
leads plus a chest lead (using the white wire - usually placed in the V1
position). This is a versatile monitoring cable, if you have one and lend
it out - you may not get it back.

A 10 wire cable is for recording a 12 lead ecg.

What type of ecg are you doing?

Do you have the patient on a monitor, or are you recording a 12 lead
ecg? Your needs will differ.

Monitoring
If monitoring for changes in rhythm, you are interested in what
the ventricles and atria are doing. As long as you can see clearly big
and small waves of activity from these two areas, you can work out
the rhythm. Choose the lead that gives the best picture of what
you are interested in; the size/shape of the p wave and/or the qrs.
it's often lead II, lead I or a chest lead, but your choice may be limited
by injuries, dressings or the patients position. But where should the
electrodes be placed, wrist, forearm, upper arm, shoulder, lower or
upper leg or even on the torso in a square box arrangement - it does
not matter, getting a good signal is more important than precise
electrode positioning when monitoring rhythm. It's common to
place the red wire on the right shoulder, yellow on the left shoulder
and green (or black) at the apex of the heart, it may not look much
like a triangle but it will produce a fairly good lead I and II when you
turn the lead selector switch. Then we come to the old argument about
"bony" or "muscular" area beneath the electrode. Well it's six of one to
half a dozen of the other; bone is not such a good conductor but is less
likely to produce muscular interference near to the electrode, muscle is
a better conductor but more likely to introduce interference.
Remember that if you turn up the gain (increase the size of the trace)
on the monitor, you also increase the size of any interference.

Common sense would tell you that the further you are from the heart
the smaller the waves of activity will be, but there will be no difference
in time intervals; p-r interval etc. So get in close, but not so close that
you might interfere with attempts at defibrillation or cardioversion.
And a patient monitored in bed with electrodes on their wrists and
ankles would not be as happy as one with electrodes on their torso.

If monitoring for ischaemic changes, you will be interested in a

particular area of the heart. Usually a chest lead is used (you can get
closer to the area involved), try to get the correct position (more on
this later), but more importantly be consistent with the position if the
electrodes are changed.

So why do people put electrodes in different

places for monitoring?
I mentioned using different leads to obtain different views, in other
words turning the lead selector switch on the monitor to a different
lead position. Most monitors give you leads I, II and III. BUT some
simple monitors have no lead selector switch, they're usually fixed to
give you lead I (but check the operators manual). These machines
often have a cable with 3 wires; red, yellow and black. I mentioned
above that for simple monitoring the red is on the right shoulder,
yellow on the left shoulder and black at the apex. Now if the machine
is giving you a lead I trace, it's using red and yellow with yellow doing
the "looking" or detecting, the black is acting as an earth connection.
If you put the yellow down at the apex, and move the black up to the
left shoulder, you've changed the angle across the chest, in fact you've
fooled the machine into giving you a lead II trace. The position of the
black wire is not that important in this situation, that's why in the
operating theatre you will often see the black wire attached to an
electrode on the patients forehead or arm, to keep it out of the way.

Instead of turning a switch to obtain different leads, we are

changing the position of the electrodes. But don't do this if your
monitor has a lead selector switch or you will screw up the views that
leads I II and III give you.
Important point
I once had a prolonged argument with a senior cardiographer who
insisted that the black wire never records anything and is only an
earth connection. This is true with 12 lead ecg's, but is not always so
with monitoring.

If your monitor has 3 wires; red, yellow, black, and has a lead
selector switch, and the shape of the complex changes when you turn
the switch to different positions.
You are using red and yellow for lead I, red and black for lead II,
yellow and black for lead III.

Other monitoring leads

We saw above that moving electrodes to different positions can "fool"
the monitor into providing a different lead or view.
A popular monitoring lead is MCL1 (stands for modified central lead
one), this fools the monitor into giving you a simulated lead V1, here's
how. With a 3 wire cable; put the red wire on the left shoulder just
below the clavicle, black (or green) on the right shoulder, yellow in 4th
intercostal space on the right sternal border (the V1 position), if
there's a lead selector switch set it to lead I. Alternatively, if you put
the black (or green) in the V6 electrode position, turning the lead
selector switch to lead II would give you a simulated lead V6.

MCL1 is a useful monitoring lead, it usually gives good waves for

rhythm analysis and is the best lead for identification of bundle branch
blocks.

Many different configurations are possible using a 3 wire system, and

some of these have been forgotten such as; CS5 (MCR5), CM5, CB5,
CC5. To make sense of any of these modified leads you must consider
what lead has been selected on the monitor, and which wires it
therefore uses, in particular which wire is doing the "looking".

Telemetry and Holter monitoring can offer single, dual or multiple lead
configurations which make use of combinations of limb leads I, II and
III with modified chest leads.

If you make a paper recording of a rhythm strip you must write

on it what lead (or simulated lead) was used.
Electrodes
Please please please do not leave electrodes attached to the patient
cable, or put neatly arranged rows of electrodes "ready to go" on the
arrest trolley unless they are used on a daily basis. The electrode gel
will dry out and be useless. I once attended an "arrest" on a ward
where the resus trolley was used perhaps once every couple of
months, every electrode had to be thrown away because they had
dried out. If you do find yourself in this situation, break out some
normal saline and put a spot on the dried out gel pad, it should work.
You may like to know that Lewes published a paper in the British Heart
Journal in 1965 showing that ketchup, mayonnaise, toothpaste and K-
Y jelly all produced equally good results as electrode gel.

The twelve lead ecg

Let's split this into 6 chest leads and 6 limb leads.

The six chest leads

The electrodes for the chest leads MUST go in the standard
positions:

• V1 - Fourth intercostal space, right sternal border.

• V2 - Fourth intercostal space, left sternal border.
• V3 - Midway between V2 and V4.
• V4 - Fifth intercostal space, left midclavicular line.
• V5 - Level with V4, left anterior axillary line.
• V6 - Level with V4, left mid axillary line.

In female patients electrodes are NEVER placed on top of the breast

unless you cannot gain access to the normal position. If you do have
to move onto the breast, write it on the recording.

However, having said that, I'm grateful to PWharmby@aol.com for

telling me about the following:
"Breast tissue appears to have a practically negligible effect on ECG
amplitudes, and in women, the placement of chest electrodes on the
breast rather than under the breast is recommended in order to
facilitate the precision of electrode placement at the correct horizontal
level and at the correct lateral positions."
Rautaharju PM, Park L, Rautaharju FS, Crow R. A standardized
procedure for locating and documenting ECG chest electrode positions:
consideration of the effect of breast tissue on ECG amplitudes in
women. J Electrocardiol. 1998 Jan;31(1):17-29.

V1 is the important starting point, if you get this wrong the whole lot
will be wrong. It can be difficult locating the fourth intercostal space.
The best way is to run your fingers down the sternum, starting at the
heads of the clavicles, until you meet a bony horizontal ridge (the
sternal angle or angle of Louis), this is easier to find in male patients.
With your finger on this ridge, slide it to the patients right, your finger
will drop into an intercostal space, this is the second intercostal space,
now move down to the third and then the fourth, here's where you
place V1.

The most important aspect of 12 lead ecg recording is

consistency of recording technique, but positioning of
electrodes comes a close second.

When using the 12 lead ecg to look for evidence of ischaemia or

infarction, we are not so much interested in a single 12 lead recording
(though it may be conclusive on its own), but how it changes over
time - we are comparing recordings. If these records were not all
made the same way the reliability of comparison is lost.

If you think the chest electrodes are in the wrong place, and a
recording was previously made (say 10 minutes ago). DON'T change
the electrodes to the "correct" positions until you have made a final
recording using those same electrodes. Then do a "proper" recording
and write on it that the electrodes were repositioned.

An extreme example

Say I put an electrode on my nose and one on my big toe, I would

record some activity. Then 20 minutes later I make another recording
using my nose and big toe. I could compare it to the first, I could say
if there were changes. It would be of use.

Once you've placed the chest electrodes and made a recording leave
them alone.
Extra chest leads
It's often useful to look further round the heart than V1 to V6. You can
do "right chest leads", designated as V1R to V6R - a mirror image of
the normal chest leads. Remember that your normal V2 is in fact V1R,
and normal V1 is V2R, so to include a "right" set of chest leads just
record V3R to V6R.

Posterior leads can be useful. V7 is level with V6 in the left posterior

axillary line, V8 is level with V7 at the left midscapular line (often
taken as midway between V7 and V9), and V9 is level with V7 at the
left spinal border.

If a chest lead is recorded from the tip of the ensiform (xiphoid)

process, it is designated with a lower case "e", as in Ve.

Remember that to record these extra leads you would have to

reposition some of the wires to the new electrode positions, the
machine will not know you have done this. It will still print "V1" or
"V6" or whatever next to the tracing, you must cross this out and write
the new lead position.

The 15 lead ecg

Some 12 lead ecg machines have the capability of recording some or
all of these extra leads. On some models of the Hewlett Packard
Pagewriter look at the large plastic block that holds the wires that go
off to the limb and chest connections. You may see some extra slots
for wires to be plugged in, labelled as C3R etc. Just add the wires and
reconfigure the machine setup to print a 15 lead ecg (standard 12 lead
plus three extra chest leads).

The six limb leads of the 12 lead ecg

Last, but certainly by no means least. The topic that generates the
most arguments, is it wrists arms or shoulders for the arm
connections, and ankles thighs or hips for the leg connections..
First an historical perspective. Very early ecg recordings were
made by having the patient lie down with the ends of their arms and
legs dipped in buckets of salt water (only limb leads were used
originally) in order to make the required electrical connections. Then
someone came up with the idea of using a saline soaked pad placed
around the wrist or ankle, with a metal plate on top - secured by a
rubber strap, which can have a wire attached that goes to the
recording device - no more buckets. Then we get the idea to replace
the saline soaked pad with some conductive jelly between the metal
plate and the skin - everyone stays dry, but we still need the rubber
strap to hold them in place.

At this point it's worth noting that although the arms and legs can be
likened to "wires" hanging off the torso; the impulse that reaches say
the right arm has to travel from the right shoulder to get there. It
would have required a very "Heath Robinson" Victorian type
contraption to strap electrodes to the shoulders and groin, it was just
easier to put the connections on the wrists and ankles.

Then we get adhesive electrodes, and everyone goes crazy. It's now
realised that you're not limited to wrists and ankles when choosing a
site for the electrode. Move closer to the heart (shoulders and groin)
and you get a stronger signal, plus you are less likely to pick up
skeletal muscular interference or tremor. And female patients don't
have to remove their tights.

How this can affect the 12 lead ecg

Analysis of the 12 lead ecg is all about measurements, the height and
depth of waves can be important in the diagnosis of certain conditions
such as infarction or hypertrophy. Technically there will be a slight
difference in size of waves seen in the limb leads if you record a limb
lead from a torso connection compared to a limb connection. But this
will not affect the complexes in the chest leads.

The following changes in the 12 lead ecg have been shown to occur
when the 4 limb electrodes are placed on the torso;

• A shift in the cardiac axis towards the right.

• R wave becomes smaller in lead I.
• Less prominent Q waves in inferior leads.

Bartosik J, Pahlm O, Edenbrandt L, et al. Reconstruction of the standard 12-lead ECG

from recordings using nonstandard activity-compatible proximal limb lead positions. J
Electrocardiol 1995 Jan; 28(1):33-8.

An example of different limb electrode positions

I'm grateful to Kerry Smith, Clinical Coordinator of the Arrhythmia
Technologies Institute for sending me these striking examples of how
evidence of an inferior MI can "disappear" by moving the limb
electrodes to the torso.

So what are the correct positions for the limb

electrodes
According to the American Heart Association, "The electrodes may be
placed on any part of the arms or of the left leg as long as they are
below the shoulders in the former and below the inguinal fold anterioly
and the gluteal fold posterioly in the latter. Any other placement
necessary by deformed or missing extremities must be noted on the
record."

Pipberger HV, Arzbaecher RC, Berson AS, et al. Recommendations for

standardization of leads and of specifications for instruments in
electrocardiography and vectorcardiography: Report of the Committee
on Electrocardiography, American Heart Association. Circulation
1975;52:11Ð31.

You can not compare an ecg recorded with

torso limb lead placement, with a
standard ecg.
But you could compare a series of ecg's recorded in such a way.
For the analysis of serial changes (such as in ischaemia / infarction),
consistency of recording technique is important.

There may be times when you need to digress from standard

technique. Say the patient had a peripheral muscular tremor, you may
get a better quality recording by using torso limb lead placement.

If your department/unit/ward/hospital or clinic places the arm

connections on the upper arms or shoulders, just make sure everyone
does it the same way. Then all recordings are comparable (but not in
different parts of the country or the world).
There is a recognised international standard for placement of the limb
electrodes (as well as the chest connections), wrists and ankles. If you
want to do it different, fine, so long as everyone you work with knows
and agrees (that's the hard part).

If you record a 12 lead ecg with any aspect of recording technique

differing from the standard (see below), write what you have done on
the recording. For example "Torso placement of limb electrodes".

Many practitioners now give patients a copy of their last recorded ecg.
This is an excellent idea, that recording will be useful to any future
paramedic, nurse, or doctor. But it would be best to record it the
standard way; patient supine, arms by their side, chest electrodes in
their correct positions, limb electrodes on wrists and ankles, recorded
at 25mm/sec, calibrated at 10mm/mV.

Having said all of this, there is bound to be someone somewhere who

will disagree with something said.
If so, do please get in touch.