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