# Limb Lead Placement on 12 Lead EKG



## rling (Sep 19, 2008)

How do you apply your limb leads?

Back in medic school, I remember an instructor telling us once that all limb leads should be placed on the same portion of the limbs equidistant away from the heart and other limb leads, ie: if the lower leads are placed on the calves, they should be applied to the lower segment of the arms as well - the forearms. I've also seen folks put them on the upper chest (just below the clavicles on the mid-anterior axilllary line, close to the anterior deltoid) and on the abdomen region - just above the hips. 

I ask this because at my work, everyone seems to put them on the shoulders and calves, which seems to go against what I had learned. When I have done my own 12 leads, I have been comfortable in keeping all my leads in the torso, ie. precordial leads where they typically go and limb leads (as described above) on the upper lateral chest and down by the upper margin of the hips. The ekg seems to turn out fine, but unfortunately my FTO's have looked at me like I'm stupid and don't know what I'm doing.

I suppose I need to just test these methods out on myself one day, but I'm curious what you folks think/know/feel about the placement of the leads.


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## mikie (Sep 19, 2008)

*thank you!*

I've been meaning to ask that question.  Our LP12 uses limb-leads, with supplemental 12 lead (can be attached).  Some providers place them on the chest and some on the arm...what's the deal here!??


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## Northstar453 (Sep 19, 2008)

I was told that when setting up a 12-lead that the Limb leads go on the limbs, as to a specific site on the limbs, its doesn't matter as long as they are a "meaty" part of the limbs.  I was also told that placing the limb leads on the chest and abdomen during a 12 lead can bring about a false reading in the 12 lead.  

This is what I have been told by some of the medics that I work with, whether or not it is totally accurate or just personal preference to lead placement.


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## Ridryder911 (Sep 19, 2008)

There is a article in this months JEMS magazine in regards upon how important limb lead placement is. 

http://www.jems.com/news_and_articles/articles/jems/3309/misleading.html


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## Hastings (Sep 19, 2008)

You have an official answer above, but just to relate to the "what I've learned in school" part of your post...

We were taught two things:

1. The more distal, the more accurate (strangely).
2. Always place the leads the same distance away from the heart.

Meaning if you put them above the ankles, put them on the forearms. Put them on the lower abdomen? Then the others go near the shoulders.

That's what we learned. And really, that's what I find more effective. Personally, I always put them on the forearms, near the wrists, and above the ankles when possible. I've found it most accurate and most convenient.


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## el Murpharino (Sep 19, 2008)

Strange how when given some latitude as to where to put the "stickers", we find a way to screw it up.  Bob Page taught the class I was in (and others, I'm sure) that the limb leads go on the limbs, not the shoulders, upper chest, abdomen, etc, and not over any bony areas.  I usually use the anterior forearm area, and the calves for my limb lead placement.


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## So. IL Medic (Sep 20, 2008)

Hastings said:


> 1. The more distal, the more accurate (strangely).
> QUOTE]
> 
> Not so strange when you think about it. The father away from the heart, the greater the signal/noise ratio in a sense.
> ...


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## pumper12fireman (Sep 22, 2008)

I was taught that they are LIMB leads for a reason, and to place them on the calves/thighs and shoulders/arms. Not on the chest, or just superior to the clavicles. I have noticed, however, that most hospital 3-leads are not long enough to accomplish this and you have to put them on the chest. I've also got some weird looks from nurses while trying to put the 3-lead on the limbs..


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## MSDeltaFlt (Sep 22, 2008)

Ridryder911 said:


> There is a article in this months JEMS magazine in regards upon how important limb lead placement is.
> 
> http://www.jems.com/news_and_articles/articles/jems/3309/misleading.html




Tried searching, but couldn't find it.  What would benefit a lot people, in my honest opinion, would be to see some examples of proper and improper ECG placement.  The only ones I found showed reversed limb lead placement; not limb lead placement on thorax instead of limbs.


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## reaper (Sep 23, 2008)

This is a pet peeve of mine. When I get new partners or students, I have to reteach them placement. I always place limb leads on the upper biceps and the medial calf. In a 12 lead, this is a must. If I am just monitoring and do not have easy leg access, then I will allow abd placement of the leg leads.

Placing the arm leads on the upper bicep, keeps them out of your way when preforming a bp or IV.


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## mikie (Sep 23, 2008)

We had mixed reviews.  If we only intend to do the limb lead (no XII), some providers would place them on the chest, some on the arms.

Just for 4 lead, does that 'create a problem?'  Is the monitor more likely to 'be inaccurate?'  

Also, why is it that for the basic ECG, the LP12 (ours at least) uses limb leads (when not doing a full XII)?


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## Ridryder911 (Sep 23, 2008)

MSDeltaFlt said:


> Tried searching, but couldn't find it.  What would benefit a lot people, in my honest opinion, would be to see some examples of proper and improper ECG placement.  The only ones I found showed reversed limb lead placement; not limb lead placement on thorax instead of limbs.



I don't understand, it directed right to it. It is also in this months journal & discusses what you had described. 

R/r 911


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## MSDeltaFlt (Sep 23, 2008)

It says to see figure "this" or figure "that".  I see no "figures" at all.  Nor do I see any links to access outside of the nobel prize link for Einthoven and the link to contact the one who wrote the article.  I don't understand it either.


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## rjz (Sep 23, 2008)

We use LP-12 monitors and obtain 12 leads when needed. If I am jsut puttign someone on the monitor I will use the chest and abdomen as this seems to reduce the amount of artifact that is picked up. If I am going to perform a 12 lead then I place the limb leads on the limbs as indicated in the article. I like the article as it is descriptive in what needs to be done and provides justification for the methods.


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## MasterIntubator (Sep 27, 2008)

The cardiology unit at MCV-VCU ( Va medical university ) did a study a few years back, and found that the limb placement really did not make a significant enough problem to even be concerned about ( assuming they are oriented correctly ( RA to upper right side, LL to left lower side , etc ).

The V leads are the ones that if placed off margin, they will give you some erroneous results.  You should be picky on these placement.

Just what they concluded to.  

Me personally, I place the limb leads as close to the chest as I can, or on the thoracic area.  I get less interference bouncing down the road.  I also will not be looking that in depth for such minute changes either, I'll leave that for the cardiologist in his quiet non-moving office.  When there are significant changes ( even posterior/right sided MIs.... I will still see them.

But thats just my experience.


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## Resc-U-Randy (Sep 28, 2008)

According to what was learned in school was if the lead was placed more distally, you would get a better picture.  But it also depends on the patient.  If there is a neurological or physical defecit, you would place the leads closer to the abdomen.  But it also depends on the Medic.  The tracing would pick up more artifact the closer you get to the abdomen.


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## Resc-U-Randy (Sep 28, 2008)

mikie333 said:


> We had mixed reviews.  If we only intend to do the limb lead (no XII), some providers would place them on the chest, some on the arms.
> 
> Just for 4 lead, does that 'create a problem?'  Is the monitor more likely to 'be inaccurate?'
> 
> Also, why is it that for the basic ECG, the LP12 (ours at least) uses limb leads (when not doing a full XII)?


The LP12 can be used in either monitor or diagnostic mode.  If you suspect a MI, you can get an EKG tracing without hooking up the precordial leads.


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## Markhk (Sep 29, 2008)

Resc-U-Randy said:


> If you suspect a MI, you can get an EKG tracing without hooking up the precordial leads.



Wait...if you don't hook up the precordial leads (V1-V6), your 12-lead software can't interpret for an anterior (V3, V4), septal (V1, V2) or lateral (V5,V6)  MI...you would only be able to look at the inferior aspects of the heart (Leads II, III and AVF) if you had the 4-lead on.


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## reaper (Sep 29, 2008)

Resc-U-Randy said:


> The LP12 can be used in either monitor or diagnostic mode.  If you suspect a MI, you can get an EKG tracing without hooking up the precordial leads.




Of course you can get a tracing, but it is not going to tell you anything!


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## Resc-U-Randy (Sep 29, 2008)

It opens up the "window" and lets in more information than in monitor mode. Diagnostic mode can filter out alot of information you may need for correct interpretation.  This way is not going to show where the MI is, but can be useful for determination of an Inferior STEMI


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## reaper (Sep 29, 2008)

Huh????????


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## Markhk (Sep 29, 2008)

You need to interpret the EKG in diagnostic mode. Monitor mode may provide a reading with less artifact, but it will prevent you from getting all the information. (I think you have the two mixed up...)

Also, you do realize that an anterior MI is the most common type of STEMI right? You really do need those precordial leads...

These are two great videos to watch about 12-leads by the way:

http://www.youtube.com/watch?v=eA5HmQSMGHE

http://www.youtube.com/watch?v=TFcyiCKyaZ4


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## Resc-U-Randy (Sep 29, 2008)

Right. I did get them mixed.  It gives an overviewfor the varitable "Load and Go" patient.


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## Zippo1969 (Oct 12, 2008)

12 lead ECGs can only accurately interpret axis (the predominant direction of the flow of electricity through the heart) with the LIMB leads on the limbs - deltoids and thighs are fine for this - 

axis determinations are vital in diagnosing hemiblocks / fascicular blocks of the bundle branches.  One could also argue that incorrect lead placement could give skewed results of infarct location, and amplitude variances, but personally I believe that's a bit over the top, and it's sounds as though studies have demonstrated those two problems as being irrelevant.

The key is good skin prep - most artifact comes from poor conduction - not placement.

On a side note - telemetry beds were the original 'movers of the leads', as they migrated inward to the torso to prevent ICU V-tach alarms from sounding every time a patient brushed their teeth...


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