12 Lead EKG Electrode Placement

MMiz

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Are providers actually palpating and counting intercostals when placing electrodes?
 

DesertMedic66

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When I first started doing it and when I teach it, yes. I haven’t actually palpated it in a long time nor have I seen any providers at any levels do so.
 

Tigger

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If I can’t really see where the fourth space is I’ll feel for that before I put v1 and v2 on.
 

akflightmedic

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Did when I first started and do when I teach. After a while, eyeballing is pretty sufficient. And if pads are in place the lead placement is even more creative. Or if for some odd reason the cardiologist actually happens to be bedside and is wanting a repeat EKG along with a right sided and then a posterior….yeh placement mattered that one time. Lol
 

DrParasite

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When I first started doing it and when I teach it, yes. I haven’t actually palpated it in a long time nor have I seen any providers at any levels do so.
so.... does it really matter? meaning, how important is it to be exactly accurate on the anatomical landmarks?

is it clinically significant if you are an inch or so off, because you are eyeballing it? i remember in medic school, we had one guy be our test dummy (the guy has no hair on his chest at all), so we took a 12 lead using the anatomical marks.... and then we moved the leads a bit. there was little to no visible change in the 12 lead. so we moved them again, with the same results. it was a minor change, barely noticeable, but doubtful if it was clinically significant.

I'm not saying you can stick them anywhere and magically it will work, but if you are the right area (ie, eye balling it), and the leads are in the right sequence and secured to the skin, is it really that critical to get the exact anatomical location correct?
 

DesertMedic66

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so.... does it really matter? meaning, how important is it to be exactly accurate on the anatomical landmarks?

is it clinically significant if you are an inch or so off, because you are eyeballing it? i remember in medic school, we had one guy be our test dummy (the guy has no hair on his chest at all), so we took a 12 lead using the anatomical marks.... and then we moved the leads a bit. there was little to no visible change in the 12 lead. so we moved them again, with the same results. it was a minor change, barely noticeable, but doubtful if it was clinically significant.

I'm not saying you can stick them anywhere and magically it will work, but if you are the right area (ie, eye balling it), and the leads are in the right sequence and secured to the skin, is it really that critical to get the exact anatomical location correct?
As long as they are somewhat close I don’t think it would make much of a difference but I could be wrong. My 12-lead skills are very dusty as we don’t do them much on the flight side and all the times I have done it, the patient has already been identified as having a STEMI by the sending facility or EMS. @Aprz might have more input on placement causing changes on the 12-lead.
 

E tank

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Adult hearts are a variety of sizes and have a certain variability in how they lay and are positioned in the chest. Leads being a few mm's off of the textbook position don't mean much.
 

Aprz

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Personally, I don't think it matters much. It will cause changes that are not clinically useful in my opinion. Like people talk about putting the limb leads on the limbs vs torso. This causes rightward axis change, but most clinicians (not just paramedics) cannot even tell axis anyways and it is not usually that helpful with interpretation. Those who can even interpret axis seem to use it more dangerously.

clinician: oh, it is not extreme right axis deviation? It's not VT.
narrator: but it was VT.

Most common issue with precordial lead placement is they are placed too high. This can cause a pseudo or incomplete right bundle branch block pattern, an rSr' wave in lead V1. This can make people incorrectly interpret incomplete right bundle branch block or they might think it is right ventricular strain pattern like from a pulmonary embolism. Next most common lead is people can't figure out where to put V3, which somewhat messed up R wave progression. R wave progression is useful in recognizing anterior or posterior wall MIs, left anterior fascicular blocks, and left ventriculcar aneuryms. Amal Mattu used to teach RV3 <3 equals poor R wave progression, but that is without looking at the overall pictute. It's usually a clue to these conditions, one of the first things I might notice or quickly see, but not absolutely essentially to have to diagnose. It just throws off the pattern so V3 might look more like V2 or V4 (usually people put it too close to those leads) so it makes V3 useless. V3 is sometimes used for looking for left ventricular hypetrophy using modified cornell method. A lot of these things, clinicians (not just paramedics) will not being thinking or looking for. They likely don't even know about these things anyways.
 

BobBarker

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Eyeball it works for us. Like someone said here, it gets creative with pads on also lol.
In regards to limb vs torso placement, we do limbs now (used to do torso but the CCTRN I work with now prefers arms/legs) but when we get to any Kaiser ER, the techs and RN's put their 12 lead limb leads on the torso. The 3 times I've actually compared the 12 leads, we found no significant difference.
 

Mitchellmvhs

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Very interesting thread. Im a basic and was so adamant on correct anatomical position when I first started, but I’ve become lazy and I’ve asked 2 of my previous medic partners how much it affects the 12-lead if the placement isn’t in the actual intercostal space. And both have told me as long as it’s not extremely off there’s really not a huge difference that they can see. My current partner did tell me sometimes he can see a difference for limb leads vs torso with extremely weird Rythms he’s having trouble reading.

But then again I’m a basic so… squiggly lines lol.
 

DrParasite

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My current partner did tell me sometimes he can see a difference for limb leads vs torso with extremely weird Rythms he’s having trouble reading.
did your partner explain why? the only reason I was told (aside from personal preference) is if the patient has Parkinson's, or is shaking a lot, the torso results in less artifact. Otherwise, they are called limb leads for a reason...
But then again I’m a basic so… squiggly lines lol.
#DangerSquiggles
 

Akulahawk

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WRT to Limb vs Torso placement, the machines we use at work have a user selectable setting for this. You can choose which placement you're using. That way the machine can make the appropriate adjustment so that the output is also appropriate for axis determination. We use primarily torso placement so our machines are defaulted to that. Most of the people that do the 12 leads just eyeball the V lead placements. Worst case scenario is that we palpate for V1/V2 placement and then eyeball off that.
 

Mitchellmvhs

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did your partner explain why? the only reason I was told (aside from personal preference) is if the patient has Parkinson's, or is shaking a lot, the torso results in less artifact. Otherwise, they are called limb leads for a reason...

#DangerSquiggles
He pretty much explained it as a different view of the heart. But I’ve worked with CCT who preferred torso leads for that reason.

He told me as well the only time he’s even gotten lash for torso leads was from a doctor. But that doctor was just kinda anal about everything.
 

fm_emt

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I took Bob Page's 12 lead class recently and now I am terrified to put them on the torso again. :O
 

DrParasite

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I took Bob Page's 12 lead class recently and now I am terrified to put them on the torso again. :O
can you elaborate as to why?
 

ChrisEMTA

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I do personally just because I like to be efficient. Sometimes I feel as it's not needed like when a child is hyperventilating it seems easier but I do palp the area just for confirmation
 

fm_emt

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can you elaborate as to why?
the class talked about how limb leads stuck on the torso might avoid some artifact but can cause over-augmentation and exaggerated ST segments, making a 12 lead non-diagnostic. If misplaced, they can also cause issues with axis determination. I know people say "oh, that's not true, they're fine on the torso, that's nonsense" but studies have shown placement is important.
 
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