# Limb lead electrode placement ???



## omak42 (Aug 25, 2011)

So I know this has been brought up before on here but I needed to ask a question regarding it.....
Anyone know where I can find a STUDY that supports the statement of limb leads being placed on the limbs vs on the torso?

I have always been taught to place them on the arms and legs and only go to the torso if quality of the EKG is sacrificed by normal placement.  However, recently the micro managing of my place of work has come out in the form of a memo stating that we are to only place the electrodes on the torso as this is what Physio Control said is favorable when only monitoring an ekg (not performing a 12 lead) and for whatever reason everyone in this area seems to be instructing as proper placement.

I'm trying to prove that this is not the case.  I have already received a statement from a Physio Control lead clinician stating that the limb leads should be placed on the arms/legs, but am trying to find a study that supports this with results.  

Ideas???


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## STXmedic (Aug 25, 2011)

My Ops Chief has actually done a study on it when he worked with a couple cardiologists. We are trying to convince him to publish it, but he's not biting.


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## DesertMedic66 (Aug 25, 2011)

Well they are limb leads and not torso leads....


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## omak42 (Aug 26, 2011)

not arguing with you here.....

you need to convince him to give you a copy at least....lol

but seriously, who sends out a memo dictating where to place the electrodes???  especially since this person isnt even a medic.


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## MasterIntubator (Aug 26, 2011)

You may have to dig a lot, but many cardiologists and cardio nurses did a study at MCV-VCU years ago ( Vivian Biggers, RN ) and found that limb leads on the torso make very little difference other than lessening the artifact.

I have researched this extensively and concluded that; I'm not in a hospital setting as a cardiologist, my hospital moves and bounces, my patient does not lie still... I want the best quality recording with the best possible accuracy out in the field.  It has never let me down, and when they are having a STEMI, you will know it and see it.  The chest leads you need to be as close as point on as possible.  Even then, if you are a rib off.... you will see the big gun damage.  CP is going to get treated appropriately no matter the tracing, STEMI makes me step it up a notch on early notification.  NSTEMI and Angina are pain management priorities and they normally have time for further diagnostics.
I have yet to see any significant axis change between the limb vs chest placement.  Granted.. I don't shove the limb leads mid-clavicular... they are on the shoulder over the humeral head, and just above the illiac crest laterally

Now... for the cardioparamedicologists out there, according to our cardiologist, proper limb lead placement is anywhere distal to the humeral and femoral head, and they mirror each other. 

After that.... its just personal preference.  Just be accurate with the V leads.

Hope this helps a little....


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## AlphaButch (Aug 26, 2011)

google - Heart Rhythm 2007;4:394-412

I don't have the web link for the article, but it's the 2007 ECG Statement by the AHA. Has a whole bunch of studies listed in the references.

I've read many journals which promote the EASI placement over the standard ML placement or Distal placement. However, this only applies if you are actually reading the strip NOT if you're allowing the machine to read it for you (tsk tsk).

Placement did not change treatment statistically when diagnosed by clinicians who were aware of the lead placement. 

Variations due to placement did change and cause diagnostic errors when computer analyzed (since monitors don't take into account the varied lead placement) by up to 6% - cite; Schijvenaars BJ, Kors JA, van Herpen G, Kornreich F, van Bemmel JH. "Effect of electrode positioning on ECG interpretation by computer. J Electrocardiol 1997;30

Nutshell;

If you're reading it, you can get a better picture using EASI or Torso placement (assuming you know the slight deviations that will occur). 

If the machine is analyzing the strip, place the leads in the manner that the machine's programmers used.


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## truetiger (Aug 26, 2011)

I think this is the answer you were looking for, taken from the Multi-Lead Medic handout.

"So why do so many people put the electrodes on the chest?  This is an example of another 
paradigm or “the way we’ve always done it!”  In all fairness, the leads were moved into the 
chest to reduce artifact in the hospital setting where remote monitoring is allowed. However, 
by placing the electrodes on the chest, you can only monitor the rhythm.  In order to assess 
for the patient axis, hemiblocks and bundle branch blocks, you must have the leads on the 
LIMBS!  Oh, by the way, if artifact is a problem, have the patient lie still while you get the 
ECG!"


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## DrParasite (Aug 26, 2011)

firefite said:


> Well they are limb leads and not torso leads....


sounds like the best answer I have heard


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## Aidey (Aug 26, 2011)

I will have to see if I can find it, but when I was researching this a while ago I found a website that had example 12 leads of different limb placement. Moving the inferior limb leads onto the torso changed the T wave morphology enough that it hid clinical ST elevation.

I personally had an example where the QRS deflection in the precordial leads was opposite when the leads were placed on the torso vs the limbs. I would post it, but I gave it to our training department to use.


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## jwk (Aug 26, 2011)

We use torso leads almost exclusively in surgery.


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## truetiger (Aug 26, 2011)

Yes, but in surgery you are monitoring the patient, not performing a diagnostic 12 lead


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## jwk (Aug 26, 2011)

truetiger said:


> Yes, but in surgery you are monitoring the patient, not performing a diagnostic 12 lead



Actually we can do both.


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## ekgpress (Aug 31, 2011)

Large ongoing discussion . . . but my Gestalt is that there MAY be a difference in the ECG when lead placement is different (torso vs limbs).  A bigger question of course is how much this matters ... with the answer depending on the setting.  In most cases - the difference will be minimal, and it may clearly be advantageous to get a better quality tracing with more proximal lead placement.  That said - measurements for hypertrophy, axis for detection of hemiblocks, and even Q waves may change sometimes surprisingly by enough to change the final interpretation.  I agree that in general (probably 98-plus% of cases) - if your role is that of EMS in the field - that a change in lead placement will probably not affect the on-the-scene judgement of whether or not there is STEMI ... but best to avoid the situation of inferior Q waves one day but not the next due to lead placement change. BOTTOM LINE: Be consistent. IF it is an institution or group decision to use one or the other lead placement - then EVERYONE in that group ought to follow suit.  At least there will be consistency - so that you'll still see serial change. IF any deviation (due to patient unable to lie flat; lack of limb; tremor; you-name-it) - be sure to NOTE this on the tracing that is being done so that others will know that the ECG obtained will be like comparing "apples to oranges" in terms of lead placement. Be aware that voltage (for LVH) and axis (for hemiblocks) may be different by small amounts that on occasion may affect such readings.  ST-T wave changes could be different (since the ST-T wave may change with a change in the axis ... ) - but in general limb vs torso placement will probably not affect recognition of acute STEMI - Ken Grauer, MD


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## MasterIntubator (Sep 5, 2011)

Nice


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## MSDeltaFlt (Sep 5, 2011)

omak42 said:


> So I know this has been brought up before on here but I needed to ask a question regarding it.....
> Anyone know where I can find a STUDY that supports the statement of limb leads being placed on the limbs vs on the torso?
> 
> I have always been taught to place them on the arms and legs and only go to the torso if quality of the EKG is sacrificed by normal placement.  However, recently the micro managing of my place of work has come out in the form of a memo stating that we are to only place the electrodes on the torso as this is what Physio Control said is favorable when only monitoring an ekg (not performing a 12 lead) and for whatever reason everyone in this area seems to be instructing as proper placement.
> ...



Not sure of any emperical data/studies, but the operative word here is "monitoring".  Which makes sense. When "monitoring", you're going to have the leads on for a long time. Pts do tend to move. We can't ask anyone to stay perfectly still the whole time we're caring for them.

"Assessing" is completely different. You're not doing it for very long.  And I doubt Physio Control's software doesn't have that good of a noise filter if your leads were on the limbs if the pt had to move them for some reason: signing foms, adjusting glasses, picking their nose, etc.

For that reason, torso is fine.


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## ekgpress (Sep 5, 2011)

*Lead Placement for Monitoring Rhythm vs 12-Lead Assessment*



MSDeltaFlt said:


> Not sure of any emperical data/studies, but the operative word here is "monitoring".  Which makes sense. When "monitoring", you're going to have the leads on for a long time. Pts do tend to move. We can't ask anyone to stay perfectly still the whole time we're caring for them.
> 
> "Assessing" is completely different. You're not doing it for very long.  And I doubt Physio Control's software doesn't have that good of a noise filter if your leads were on the limbs if the pt had to move them for some reason: signing foms, adjusting glasses, picking their nose, etc.
> 
> For that reason, torso is fine.


--------------------------------------------
Excellent point by Mike. When monitoring - one is principally concerned with the rhythm - so the need is primarily for good quality P wave and QRS complexes (for which torso may provide better quality recordings without need to concern oneself about  possible slight alteration in QRS and ST-T wave morphology) - Ken Grauer, MD


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