# precordial lead placement obese/large breasts



## Anonymous (May 2, 2012)

Over or under adipose tissue? For every study that says one way I find another that says the opposite. Also I have a hard time counting intercostal spaces on anyone with decent pec development or someone that is overweight. Any tips/tricks?


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## Aprz (May 2, 2012)

I'm not sure what you mean about the adipose tissue part. For the precordial leads, I think placement is the most important thing. If it was the limb leads, I wouldn't say that the placement doesn't need to be as close as possible, just their relative position from the heart (although I do believe I read something that said that it changes the morphology of the complexes depending where they are at e.g. trunk leads vs. actually on limbs).

I'd start off looking for the sternal angle (of Louise) which would represent ICS 2. Feel along the sternum for ICS 4 to start off. You can still feel along the sternum for ICS 5, and work outwards on that as best as I can. I think you would still be able to feel the sternum on a very large patient so it should help guide you/start you off.

Perhaps you're talking about whether the electrodes go on the breast or not (like a female). I've been told to put it under. Unfortunately, I can't tell you much more than that.


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## Anonymous (May 2, 2012)

Aprz said:


> I'm not sure what you mean about the adipose tissue part. For the precordial leads, I think placement is the most important thing. If it was the limb leads, I wouldn't say that the placement doesn't need to be as close as possible, just their relative position from the heart (although I do believe I read something that said that it changes the morphology of the complexes depending where they are at e.g. trunk leads vs. actually on limbs).
> 
> I'd start off looking for the sternal angle (of Louise) which would represent ICS 2. Feel along the sternum for ICS 4 to start off. You can still feel along the sternum for ICS 5, and work outwards on that as best as I can. I think you would still be able to feel the sternum on a very large patient so it should help guide you/start you off.
> 
> *Perhaps you're talking about whether the electrodes go on the breast or not (like a female). I've been told to put it under. Unfortunately, I can't tell you much more than that.*



That is what I was asking. Thank you!


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## NYMedic828 (May 2, 2012)

They go beneath the patient's breast, on the actual tissue of the chest.

No shame in saying "mam could you please use your hands to lift your breast."

Most women are more comfortable doing it themselves then having you do it for them. (others have no shame whatsoever)

Not to give you any bad habbits, but outside of a text book I don't know a single person who counts intercostals. This includes in hospital and out.


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## Anjel (May 2, 2012)

Def under the breast.

And ya I was taught 12lead placement in the ER And they told me to just guestimate. 

But I like to do it correctly if I can.


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## Maine iac (May 2, 2012)

Maybe I just have an extra saggy population in my area. Once or twice I have had to put them on top of the breast to be remotely close to their (the electrodes) correct position.

The more tissue the electrical current has to travel though the smaller the rhythm will be on the strip. So you can fiddle with the settings on the printer if you know what you are doing.


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## abckidsmom (May 2, 2012)

NYMedic828 said:


> They go beneath the patient's breast, on the actual tissue of the chest.
> 
> No shame in saying "mam could you please use your hands to lift your breast."
> 
> ...



I count every time.  Angle of Louis, 2 down, 2 more down, midclavicular, follow it around.

Not hard, and no random placement.

And since it's my job, I'm not putting any woman in the position of touching her breasts in a semi-public place.  I will take care of getting the 12 lead.


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## akflightmedic (May 2, 2012)

They come with handles, just pinch that knobby protrusion and lift.  

In all seriousness, if you do have to lift, it is best for all to lift with the back of your hand if the woman is unable to lift her own breast for whatever reason.

I count...I know a lot of people who count both in and out of the hospital. Surprised someone would say that is not the norm. Yes we do approximate based on experience but there are times where I have counted.


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## systemet (May 2, 2012)

akflightmedic said:


> I count...I know a lot of people who count both in and out of the hospital. Surprised someone would say that is not the norm. Yes we do approximate based on experience but there are times where I have counted.



Me too.  I landmark properly every time.  It takes seconds when you're familiar with it.


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## systemet (May 2, 2012)

Anonymous said:


> Over or under adipose tissue?



You mean do a cut down?  

Seriously, I think you're asking where you should place them on someone large-breasted or obese?  Typically at the margin where the breast attaches to the chest wall, just inferior to the breast itself.  With someone super-obese you may have to compromise a little.



> For every study that says one way I find another that says the opposite.



Really?  How many studies have you found that look at this?



> Also I have a hard time counting intercostal spaces on anyone with decent pec development or someone that is overweight. Any tips/tricks?



If you palpate firmly, close to the sternum, you're typically in a region where there's going to be less muscle mass / adiposity.  Then you can work laterally.

When you find the angle of Louis (the protuberance where the manubrium has fused with the sternum), move laterally.  If you hit a hard structure, you're on the second rib.  The space below is the 2nd intercostal space.  If you hit a soft structure you're already in the second intercostal space.  Work two interspaces down, and you're set for the 4th intercostal space, and can place V1 and V2.

An alternative approach is to palpate under the clavicle in the midclavicular line, where you should find the first rib.  You can then move inferiorly to the 1st intercostal space, and count your way down to the fourth space.  As this involves more medial structures, it tends to be less reliable on someone with a high body fat percentage or significant musculature.  [There's also a smal risk of mistaking the gap between the clavicle and 1st rib for the first intercostal space, if you're not familiar with the anatomy].


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## mycrofft (May 2, 2012)

Every time this comes up it's a party.:huh:


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## EMSpursuit (May 2, 2012)

In the ER we simply ask them to lift for us and cover them with a pillow case or use the back of our hand.  You gotta get an accurate placement...most important


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## Sasha (May 2, 2012)

Anonymous said:


> Over or under adipose tissue? For every study that says one way I find another that says the opposite. Also I have a hard time counting intercostal spaces on anyone with decent pec development or someone that is overweight. Any tips/tricks?



Adipose tissue... do you mean boobies?


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## EMSrush (May 2, 2012)

NYMedic828 said:


> Not to give you any bad habbits, but outside of a text book I don't know a single person who counts intercostals. This includes in hospital and out.



I do.


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## Christopher (May 2, 2012)

Never on a breast (whether it be a woman or a man's), always along the inframammary fold.

Once you lock that in mind, you just go back to the old placing V1/V2, then V4 and V6. V3/V5 are interpolated.


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## RustyShackleford (May 2, 2012)

I always find it odd how many medics are uncomfortable with either A)touching a female patients breasts or B)the ramifications of touching a female patients breasts, you are supposed to be a medical professional...some of us more than others.  If you handle yourself in a professional manner and explain to the patient what you are doing I have never run into a female patient regardless of age who is uncomfortable or apprehensive about allowing me to temporarily move some fatty tissue out of the way while I perform a medical procedure that could possibly save their life in some extreme circumstances.  You are far more likely to make a patient uncomfortable if you are stammering around acting like its the first time you have seen a pair of human breasts before.


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## abckidsmom (May 2, 2012)

RustyShackleford said:


> I always find it odd how many medics are uncomfortable with either A)touching a female patients breasts or B)the ramifications of touching a female patients breasts, you are supposed to be a medical professional...some of us more than others.  If you handle yourself in a professional manner and explain to the patient what you are doing I have never run into a female patient regardless of age who is uncomfortable or apprehensive about allowing me to temporarily move some fatty tissue out of the way while I perform a medical procedure that could possibly save their life in some extreme circumstances.  You are far more likely to make a patient uncomfortable if you are stammering around acting like its the first time you have seen a pair of human breasts before.



Absolutely. Besides which, these aren't the breasts you're looking for if you are all adolescent and giggly.


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## mycrofft (May 2, 2012)

PS: if the pt is obese, unless there is a fold of adipose tissue (fat) like an abdominal pannicle but on the rib cage, then you will not get underneath any "adipose tissue" except the "mammary tissue"...neither of which you put lead on top of if at all possible.


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## Medic2409 (May 4, 2012)

Sad but true...one...errrrrr...developed female I ran on, emergency situation, altered mentation, well, it was just easier to flop her breast up over her shoulder.

The frumunda cheese I then found was a totally different story.


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## the_negro_puppy (May 4, 2012)

I always count intercostals and try to get as accurate as possible. I've had preceptors tell me it doesn't matter but reading through relevant literature and other 12 lead resources, incorrect placement can really alter the 12 lead ECG.


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## DrParasite (May 6, 2012)

if you are going to place under, do not, I repeat, do not lift from the nipple!!!!

Just a friendly reminder for those who get confused by boobies and what to do with them


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## Sasha (May 6, 2012)

Come on. That's the most actions some of the patients will have in a long time.


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