# EKG with 4 Lead



## Asus466 (Jun 18, 2018)

Where should the 4 lead be applied to the patient specifically the leg electrodes. I read it should be placed anywhere on the leg but I was told by my partner it should not be placed on the calf's because the muscle interferes with the process.


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## DesertMedic66 (Jun 18, 2018)

In my experience avoid areas where it would be directly on a bony surface and areas where there is a ton of hair. If the patient isn’t hairy then the calf has been a great place for me.


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## Peak (Jun 19, 2018)

Depends on how correct you want to be versus how much you want to reduce artifact from a patient who won't hold still. 

For a 12 lead that we are using to actually assess axis then I tend to use a good meaty part of their forearms and lowelegs, but if they won't hold still I've definitely done shoulders and hips. Tremulous patients and smaller kids tend to fall into the latter. 

For just watching their rhythm (extended transports, critical ED patients, et cetera) I put my 3 lead just proximal to the AC joint and my LL just distal to the ribs halfway between the mid axillary and mid clavicular lines. This minimizes artifact when the patient moves, and for monitors in the hospital works well for the respiratory electrical impedance monitoring.


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## Jubal (Jul 6, 2018)

I'm just really learning 12-lead and my experience is limited to ED and one agency... BUT... outside the ed (non-emergent) its all torso.

I've actually been told NOT to put leads on the legs.  A lot seems to depend on transport times, and it's very rare for us to have more than 5-7 minutes on the ambulance.  But the medics can still get a clear picture with torso and arm placement.  Done STEMIS and tachycardia and CHF on the ambulance. A lot has to do with patient comfort and a solid diagnosis for the ed and what the other is wearing and the emergence of the situation.


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## hometownmedic5 (Jul 9, 2018)

As long as the leads describe Einthovens Triangle(plus the ground), and aren’t impeded by implanted devices, hair, etc, any placement will be suitable for rate, rhythm, and STEMI interpretation. If you want to start getting into the nuance electrocardiology world, then specific placement becomes imperative, but for the EMS world, its of less importance. I try to remain consistent. If the arm leads go on the chest, the leg leads go on the abdomen and so on. Ive never tried to acquire an ekg with the leads all cattywampus all over the body, but I suspect it might be curious to look at. If you’re a basic reading this, find out what your medic wants and do it that way. You wont score any points arguing with your medic on technique, right wrong or indifferent.

The people that will consider this heresy are usually the same people that will tell you not to take a blood sugar from a venous sample because of the contextually irrelevant difference in the reading you will get between a capillary sample and a venous sample. They aren’t *wrong*, but there are far more important hills to choose to die on.


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## Qulevrius (Aug 21, 2018)

For elderly folks, it’s actually better to slap the RL & LL on the abdomen below the navel line. Distal placement can throw false positives due to lower conductivity.


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## Aprz (Aug 22, 2018)

hometownmedic5 said:


> As long as the leads describe Einthovens Triangle(plus the ground), and aren’t impeded by implanted devices, hair, etc, any placement will be suitable for rate, rhythm, and STEMI interpretation. If you want to start getting into the nuance electrocardiology world, then specific placement becomes imperative, but for the EMS world, its of less importance. I try to remain consistent. If the arm leads go on the chest, the leg leads go on the abdomen and so on. Ive never tried to acquire an ekg with the leads all cattywampus all over the body, but I suspect it might be curious to look at. If you’re a basic reading this, find out what your medic wants and do it that way. You wont score any points arguing with your medic on technique, right wrong or indifferent.
> 
> The people that will consider this heresy are usually the same people that will tell you not to take a blood sugar from a venous sample because of the contextually irrelevant difference in the reading you will get between a capillary sample and a venous sample. They aren’t *wrong*, but there are far more important hills to choose to die on.


I feel like initially, it became more and more important for the leads to be placed correctly. Eventually, you get to that point where you recognize the patterns of lead misplacement, especially the VERY common ones like lead V1 and V2 being placed 1 intercostal space too high, lead V3 being misplaced on females due to scary boobs (in combination of lead V1 and V2 being too high because of boobs... I tend to notice "weird" R-wave progression on female patients most, lol), or the limb leads being swapped, which have easy to recognize patterns (short right arm (RA) and left arm (LA) lead vs left posterior fascicular block (LPFB) not being something you can tell with a cold read, though a LPFB being rare by itself so RA and LA reversal being more likely if you see "LPFB" by itself). I dunno. I stopped caring. Same with "limb leads go on limbs". Like it causes slight rightward axis shift, but I personally don't consider it significant enough to change how I interpret the 12-lead; I'm totally okay with Mason-Likar/torso placement. If people a really going to be anal about it though, they could document it on their PCR and/or some monitors allow you to add a comment/note "torso placement for monitoring", "torso placement to minimize artifacts", etc.

In regard to the venous vs capillary blood on glucometers, I think they need to catch up to 2018. Most glucometers can distinguish the two, and it is as easy as documenting "The patient's venous blood sugar was 128 mg/dL" vs "The patient's capillary blood sugar was 150 mg/dL". That's what I do. I actually started doing that not because I felt there was a significant difference, but because we documented if we used lancets or not on the patient's PCR, and I wanted to make it clear how I got the blood sugar/why a lancent was or wasn't documented, lol.


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## Akulahawk (Aug 22, 2018)

When it comes to using a 3 or 4 lead monitor, all I care about is that the leads are in generally the right places. These aren't going to be used for diagnostic purposes as you'd use a 12-lead for that. This is for basically determining rate/rhythm. While I generally do use lead II for this purpose, I'm not stuck only with using this particular lead. I've been known to use Lead I, III, or even MCL1 or a Lewis Lead (or other leads too) in order to minimize artifact. Probably my favorite "alternate" lead is MCL1. If I'm lucky enough to have a 5 lead monitor _and_ I'm not going to use it in a diagnostic quality mode, I usually just put the leads somewhere near the Acromion Processes and somewhere near where the anterior axillary line meets the ribs/abdomen. This puts the RL and LL leads right about where the diaphragm is so I usually can get a decent signal for Resp monitoring too... Otherwise the RL and LL leads are placed on the ASIS of each side of the pelvis. V lead usually is placed at V1 or V2. 

Where I currently work (in an ED) our 12-lead machines have an option to choose "torso" or "limb" for our limb lead placement. The torso placement is basically Acromion process and ASIS while "limb lead" placement is on the actual limbs. This does not affect our placement of V1-V6. When it comes to doing those V leads on females/women, just place the leads where they're supposed to be and if some tissue needs to be moved out of the way, either have the patient move it or use the back of your hand to do so and just focus on lead placement. While I'm sure that I've done 12-leads on some women that are just perfectly endowed (whatever that means to you) I really don't remember and... I really don't care. Just be professional about it and do your job and it'll be a non-issue for everybody.


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## phideux (Sep 2, 2018)

3 or 4 lead generally go on the shoulders and lower abdomen, I have found it to have less artifact on our monitors and bouncing down the road. The V1-V6 go in their specific locations.


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## DrParasite (Sep 3, 2018)

Well, they are called *limb* leads for a reason....

But I have seen in applied them to a patient's Limbs and also to the Torso, so I don't think it really matters that much because it seems it seems to be paramedic preference, and if that's the case, there really isn't that big of a deal, other than not pissing off your medic.


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## MSDeltaFlt (Sep 14, 2018)

Depends on if you are going to simply monitor or to assess.  If you plan on simply monitoring then it doesn't really matter.  If you are going to actually assess then LL stands for the Left freaking Leg.


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## TheEleventhHour (Oct 20, 2018)

"White on Right, Smoke over Fire."

If that helps...


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## Qulevrius (Oct 20, 2018)

I always felt like the “smoke over fire” mnemonic is overly dramatic. Here’s another one: *starting on R arm & going clockwise* Salt, Pepper, Ketchup, Relish.


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## Tigger (Oct 21, 2018)

Qulevrius said:


> For elderly folks, it’s actually better to slap the RL & LL on the abdomen below the navel line. Distal placement can throw false positives due to lower conductivity.


Citation?


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## TacticalMedStudent (Jan 3, 2019)

I’ll generally gauge a preference for the medic or physician I’m with. Some prefer calf for legs - some prefer belly. Some say belly may have less artifact - it’s all in relation to itself. 

Unless the patient is morbidly obese or has acities, cops, or something, you’re ok with belly if you want. 

It’s all about vector and conductivity.


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