# Causes/Solutions For Artifact/Bad 3/5/12/15 Lead EKG's



## medic417 (Sep 29, 2009)

So what are some causes and solutions to artifact and other bad EKG's?

Here is what I posted on another topic just to get us started.

Pre-hospital really suspect that they failed to properly clean/scuff the skin leading to a bunch of artifact. I see it way to often even with the non fire EMS. Wiping with an alcohol pad is not enough but is better than many who just place them over hair, dirt and all. 

To do it right you need hair shaved, wipe the skin, then scuff it. Use something like 3m red dot skin prep. A dry 4x4 does not scuff enough.

http://www.medexsupply.com/products/...pRollwithD.htm

The next cause sadly is often the cables are not fully connected to the machine. I have gotten into an ambulance and medics had artifact and I just reached over and pushed cable connector further into its socket and amazingly got a clean 12/15 lead. 

Another common cause is the cables developing cracks. A busy service really should replace the cables every few months, while a slow rural service might need to replace every 1-2 years. 

And yet another problem especially with older machines is electrical interference. With some machines you really needed everything off in the ambulance. 

Thats just a small list of causes.


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## Crepitus (Sep 29, 2009)

Movement used to be the big one.  

Haven't run one in quite a while so maybe with the new machines you can let the pt thrash around - dunno.


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## Melclin (Sep 29, 2009)

High voltage power lines.


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## MasterIntubator (Sep 29, 2009)

The biggest causes of interference with my 12 leads have been poor electrode contact to the pt.  
In a moving medic unit, it has been limb leads placed far down on the limbs. ( I know this has been a touchy subject.... proper placement of the leads, but in my world... it does not make a lick of difference.  I routinely perform them both ways on the same pt on longer transports, and I have yet to see a remarkable difference to call the rhythm something else... other than reduced artifact. ). I keep them on the shoulders and lower torso.

In about 5 years of doing 12 leads, probably 1-6 a day in the field... I have yet had to shave or prep anyone.  Even on my worst case scenario, fully diaphoretic hairy chested MI pt.  My diaphoretic patches don't stick well, but I find folded blanket on top of the chest to hold those leads in place has worked very well, and I get my ECG answer every time.  There has been a couple times where nothing has worked... I did not get my 12.. but based on my BLS skills and ALS knowledge, I treated the pt accordingly and did it accuratley without my advanced tools.  Sure would have been nice, but... the big picture was already staring at me.
I usually have the 12 hooked up and with a print out in about a minute, I look for big changes.  I can have it sent to the ER via telementry in about 3 minutes after obatined as well if it is warrented.  There is no time wasted, and it has been spot on with the ERs 12 leads ( minus quality ), I'm not looking for perfect, just to set the pace of my scene and my response to the ER.
( I am not claiming to be the all knowing... I did not take any special 'nerd' classes... but I do study hard and keep up with the latest, and I regularly challenge my self and re-evaluate all my techniques )

Can't say I had cracked cables from regular useage.  The physiocontrol issued cables have been very stout with our abuse, and they get disinfected numerous times a day with clorox soln ( wipe downs ).  What I do not do, is tightly roll them up, wrap them over the main cable, or allow them to dangle out of the pouch giving the false sense of 'it will be faster'.  All this has done was allowed the cables to get snagged or get caught in the zipper. ( which has been the cause of my units cable failures ).
Our years PMs catch any internal failure, but those have been rare. 
( not saying it can't happen... just sharing my experiences in QA/QI )

Am I am not contesting anything said above in previous posts... We all have to keep an open mind for any cause when things don't go right.... so having all of these in the open is a BIG plus.


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## mikie (Sep 29, 2009)

medic417 said:


> http://www.medexsupply.com/products/...pRollwithD.htm



Bad URL...:sad:


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## medic417 (Sep 29, 2009)

mikie said:


> Bad URL...:sad:



Just search 3m red dot skin prep and you will find what looks like a roll of scotch tape that is designed to scuff the skin so dead skin cells,dirt, oil, etc don't mess up your readings. 

 It is bad habit to just place leads w/o skin prepping.  There was a study done but I can't find it that showed just how much proper skin prep helped.  Might even change the poster that said they just place leads over hair and alls mind.  Maybe someone else will post it.


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## fma08 (Sep 29, 2009)

Problem: Fidgety pt.

Solution: Versed


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## cm4short (Sep 29, 2009)

fma08 said:


> Problem: Fidgety pt.
> 
> Solution: Versed



Is Versed a standing order or BHO?


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## fma08 (Sep 29, 2009)

cm4short said:


> Is Versed a standing order or BHO?



More of an IYD order...


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## MSDeltaFlt (Sep 29, 2009)

Interesting.  I've been doing 12 leads since the early 90's and I have never needed to shave or scrub a pt's chest.  Not once.


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## mycrofft (Sep 30, 2009)

*Depends on artifact.*

If the ground shield (woven wire) is broken at any point you can pick up extraneous signals from fluorescent lights etc. This breakage an occur where the cable meets the plug into the machine, or the jack which received the plug can be broken from the motherboard causing intermittent then permanent corrupted then lost signal.

If you use alligator clamps and electrodes with tabs and not snaps, the gator clamps can become fouled with electrode goo or torn electrode material, causing wandering baseline; clean with alcohol wodden swab and persistent "elbow grease".

If your wiring harness has removable clips, as you prepare to attach each one give it a little turn and seat it firmly onto the end of the wire before attaching to the electrode to assure good contact. Discard corroded clamps.

Pt movement, loose electrode contact, and damge near the wiring harness/machine interface are commoner than most causes.


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## Aidey (Sep 30, 2009)

Heating pads. Also those special recliners that raise and lower to help someone get in and out of the chair. I've had electrical interference from both of those. 

Another lovely one was a patient with an anti-parkinson's electrical implant (can't remember the actual name). We couldn't even get a 3 lead on that pt, the monitor just went haywire. (We used both ours, and the FDs just to be sure and got the same results with both).

Getting moisture between the cables and the plug-in. I've seen this happen when someone wiped down the machine with the cables unplugged. When the monitor was turned on it showed a beautiful Sinus Brady at a rate of 50.....without a single lead attached to the patient. 

And my favorite cause of artifact, the patients family grabbing onto him and saying "Don't let him die, don't let him die" (Cancer pt who routinely used cocaine....) 

In 6 years I've only seen one setting where the skin was abraded before running an EKG, and that was prior to a stress test. I've never seen it done pre-hospitally or in an ED. Now, I know that doesn't mean it isn't done, but I'm going to guess that it isn't done as frequently in the Emergency medicine setting as it is in a specialty cardiology setting (stress tests, etc). 

To be honest, even if it was an option available, I wouldn't automatically do it. I would only abrade the skin if I had failed to get a clear EKG and had troubleshot the monitor. I know it doesn't take off that much skin, but I think I would have a hard time justifying to the pt and to the doctor doing it on every single patient when the doctors themselves don't.


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## mycrofft (Sep 30, 2009)

*How about electronics in their pockets? Your pockets?*

The oldest digital watches sometimes generated a detectable signal.
Remember when the EKG reuseable electrode gel or wipes actually had an abrasive in them?


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## el Murpharino (Oct 1, 2009)

It's not just prehospital...I have routinely seen hospital staff not perform the steps Medic417 is advocating prior to performing 12-leads - more so the scuffing of the skin, but to a lesser extent the shaving and almost rarely the cleaning.  I will shave their skin if they are wooly, but I will admit to lacking on the cleaning of the skin.  

I have actually never heard of "scuffing" the skin prior to recent mention of it here.  I am curious to see how many EMS providers and in-hospital EKG techs use this technique.


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## redcrossemt (Oct 6, 2009)

I've seen reliable skin prep, including "scuffing" and cleaning, done for stress tests, holter monitoring, and for almost every patient I've seen in the ICU... Never seen more than shaving or an alcohol prep done in the ED.


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## Jersey (Oct 7, 2009)

I have never shaved or cleaned once. Mike's folded sheet over the chest works wonderfully.


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## MCGLYNN_EMTP (Oct 8, 2009)

I've had to shave the chest a few times...but when the yetti calls with chest pain...it's kind of hard to get a good contact with the skin with all of that hair in the way....I'm going to try the folded blanket method (alot less time consuming  )


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