How to Place and Acquire a 12-Lead Diagnostic EKG

[@BestPracticeMedicine]

Transcript: Hello, everybody. This is Loren and Miles with Best Practice Medicine. Today we're going to be demonstrating how to apply and acquire a diagnostic quality 12 lead ECG. The first step in acquiring a diagnostic quality 12 lead ECG is the proper position of your patient. Ideally, your patient should be in a supine position. However, some patients cannot tolerate this. If that's the case, you can put them in a Semi-Fowler's position, which is acceptable as well. For the purposes of today, so we can adequately show you the proper chest electrode position, we'll be setting Miles up just a little bit higher than we would normally. Whichever position your patient is in for the EKG, just remember to repeat that position for any follow on repeat EKGs you may acquire. The second step to acquire a diagnostic quality 12 lead ECG is to expose the area where the electrodes are going to be placed. In this case, we're going to have to remove Miles's shirt. Now that his shirt is removed, we're going to have to expose his lower limbs so we can place the limb leads. At this point, we're ready to place our limb leads. Now, a few things about limb lead placement in the 12 lead. There's only a few rules to have to adhere to to obtain a diagnostic quality ECG when placing limb leads. Number one is you want to make sure that your limb lead is on the limb, that it falls between the shoulder and the wrist. The other rule about limb leads is that you do not want to put them over bony prominences, such as the elbow here, or over large muscle groups. That's just going to increase the amount of artifact. At this point, I'm going to identify probably this area right here to place my limb lead, at least my left limb lead, and I'm going to make sure that my right limb lead, I'm going to make it in a symmetrical location. So, about the same location on the right hand side. The same rules apply for the legs. Below the hip but above the ankle, staying away from bony prominences and large muscle groups. In this case, just due to access to Miles's legs, we can go ahead and put them here, just above the ankles. Now that we've identified our limb lead electrode placement sites, we do need to select a package of electrodes. In this case, our electrodes are in date. This is a 10 pack, so we'll be using all of these for all of our lead placements. They are in date, so presumably we do have conductive gel that is not dried out on these, which is important. The other thing about these electrodes, these differ in style from EKG machine to EKG machine. These are more for the pre-hospital type of EKG monitors. In hospital, you might find a tab style. It doesn't really matter the style of EKG electrodes, placement and acquisition of the 12 lead and the principles of that remain the same despite the manufacturer. Now that we've selected our electrodes, we're going to turn our attention to proper skin preparation. The first thing to consider is the amount of body hair. In this case, with large amounts of body hair that's going to affect the adhesion of electrode and transmission of the signal through the electrode, you're going to want to take a razor, oftentimes it's a disposable safety razor, and remove the hair from the skin. The other thing to consider is the oils left on the skin as well. If you take an alcohol pad and rub the area where the electrode is going to adhere, that will remove the oils from the skin. In some cases, you might have an excessive amount of dead or dry skin. That will also affect the signal acquisition for your 12 lead. In this case, you're going to grab a 4x4 or gauze and you'll rub the area, 10 to 12 strokes, until it gets just a little bit pink, and that maneuver will remove the dead skin and improve the quality of your 12 lead ECG. At this point, with our skin prepped, we're ready to apply the limb leads. I'll take my electrodes, I will open them up. I will find the appropriate electrode. These are labeled. Right leg, left leg, right arm, and left arm. Let's go here. Now that we have the limb leads placed, we're going to turn our attention and place the chest leads, or the precordial leads. Unlike the limb lead placement, the chest leads must be exact, so there's quite a few rules to the chest lead placement in order to acquire a diagnostic quality 12 lead ECG. The first landmark that we need to find in order to place our chest leads is the fourth intercostal space. We can do this two ways. The first way to do this is to locate the angle of Louis. First, you're going to find the sternal notch and you're going to feel, or palpate, about an inch and a half below the sternal notch. You'll feel this ridge in the sternum. This is the angle of Louis. It's the junction of the sternal body and the manubrium. This slight ridge that you feel in the sternum is at the level of the second rib, so immediately to the left or right of this you will feel the actual rib. That is the second rib. Below the second rib, you will find the second intercostal space. From here, we're going to march down, feeling each rib and each space, all the way down until we find the fourth intercostal space. So, if this is the second ICS, there's the third rib. Here's the third ICS. Here's the fourth rib, and here is the fourth intercostal space. This is where we're going to place V1, just immediately to the right of the sternum. V2 is going to be placed at the same level, immediately to the left of the sternum. The second method for locating the fourth intercostal space is to palpate the clavicle. Immediately inferior to the clavicle, that rib space that you feel is the first intercostal space. So, below that, feeling for the rib in a similar technique that we did just before, that would be the second rib. Again, below that is the second intercostal space. Third rib, third intercostal space, fourth rib, and then finally the fourth intercostal space. Again, V1 goes to the right of the sternum and V2 goes immediately to the left of the sternum. Now that we have placed V1 and V2, we're going to skip V3 and find the landmark for V4. V4 lies at the fifth intercostal space, mid-clavicular line. So, now that we've found our fourth intercostal space, it's not too difficult to find the fifth. You just palpate the fifth rib, and then the space below that. What we're going to have to do now is to find the clavicle. What we're going to do is establish the full length of the clavicle and basically split the middle difference. So, once we find the full length of clavicle, we split that difference. Lead V4 is going to be placed at this level. Fifth intercostal space, mid-clavicular line. Now that we've placed lead V4, we're going to skip lead V5 and place lead V6. V6 lies at the level of lead V4, but it's at the midaxillary line. Miles, would you go ahead and lift your arm up? At this point, we're going to have to estimate where the midaxillary line is, and by the name midaxillary, it's midaxilla. So, if you locate their axilla and just draw a line directly down, this is your midaxillary line. What we're going to do is just march it perpendicular to the midaxillary line, and that's where lead 6, V6, is going to be placed. It's important to note when placing V6 that it does not follow the fifth intercostal space. You want to be perpendicular to the midaxillary line. Now that we have placed V1, V2, V4, and V6, we need to place V3 and V5 because we skipped those. This is just a matter of splitting the distance equally between the electrodes that we have placed. So, lead V3 goes halfway between V2 and V4. V5 will be placed halfway between V4 and V6. Now that we've placed all of our electrodes on the chest, we can locate our chest electrode, or precordial electrode, wires and then place them on the appropriate electrode. In this model, they are labeled V1 through V6. You may encounter a situation where these are very short, depending on the model, and it may pull your electrode out of place. If that's the case, you're going to have to probably replace the electrode, as the original electrode won't stick once that happens. Now, with this model I will have to hook up the precordial wire bundle with my four lead wire set. Now I'm ready to acquire the 12 lead ECG. Now that we're ready to acquire the 12 lead ECG, I'm going to lay Miles in a more supine position here, as we had discussed. In addition, we want his upper and lower extremities uncrossed. We want them relaxed, as to not cause any muscle tremors. So, if you can put your arms down at your side, we'll go ahead and relax the shoulders. We'll make sure the legs are not crossed. If their hands are resting on a metal bed rail, we want to make sure that's not happening. Also, there can be interference from portable electronic devices, so if you have phones or anything like that, you might want to set them a little farther away from the patient. That way, it won't affect the quality of your 12 lead. On this model, I simply press the 12 lead button and it's going to acquire the 12 lead. During this time, you want your patient just to remain still. Don't hold their breath, they just need to breath normal. After a few moments, after acquiring and analyzing the 12 lead, it should print out. And, there you have a diagnostic quality 12 lead ECG. We hope you've found this video informative and useful to your clinical practice. Tune in next time for more from BPM-TV, and as always, thanks for watching. Hey, Loren, what does this mean? That's a great question, Miles. If you want to know more about how to interpret 12 leads, go to bestpracticemedicine.com and check into one of our basic or advanced 12 lead ECG courses. Thanks.

[@islasale]

E 2 1:27

[@triniboyd2603]

OMG THANK YOU!!. I’m a CNA in a hospital and your video is spot on in technique is spot on to how we were taught during orientation. But my original work assignment I never got to put this into daily practice. Now that I am working on the inpatient floors the crash course others have taught me has helped. But your video is spot on so I can continue to familiarize myself to perfect my EKG placement skills.

[@IamMichellealways]

Same here

[@sandraegharevba5629]

You just helped me perform an ecg properly for the first time... your method of teaching is quite unique . Thank you 🙏🏾

[@BestPracticeMedicine]

We're glad to help! We love helping new and old provider refine their skills to better care for their patients!

[@JustinChan-e1v]

This medical practice lesson help me found breathing sound from ECG.

[@linerud9111]

This is the best video I found explaining where and why of placement of ECG leads. Thank you.

[@BestPracticeMedicine]

We're glad to help!

[@dianasmith7864]

this video was extremely good as am about to venture into the field as an ECG technician, i have learnd a lot. thankyou

[@brandonhinojosa4202]

Best tips I've heard yet on setting up an EKG

[@BestPracticeMedicine]

Glad to hear it!

[@asninamusa]

Thank you so much for you're help, you're video is still helping so many people. I appreciate you for taking the time to teach, the best instructor! Learned so much 😊

[@darwinahalbi9451]

The best very simple easily understood. And perfect to students and beginner s, thank you , I will recommend this to my students

[@BestPracticeMedicine]

Thanks for the kind review! Glad we can help

[@hounkanrinromulex5661]

That was helpful. I’m preparing myself to start my EKG course

[@trevavaughn5]

I wish you the best

[@pennasylvania]

Concise and to the point. Thank you 👍

[@keybornmando6929]

Simple and very clear, thanks 🙏

[@2126sammy]

Awesome video !! Thank you I will start my ECG class next week !! I am nervous 🙂

[@BestPracticeMedicine]

Best of luck from team BPM!

[@trevavaughn5]

You will do great Sammy

[@HealthSpotlight]

Thank you so much for this, Please do a video on how to check the Blood Pressure..And also in my school our leads have colours

[@MichaelJacksonzGlove]

Hi, I'm watching this because I may soon be working as patient care tech. This seems intimidating, and I'm afraid I won't memorize what goes where. I'll rewatch your video until I get it.

[@JessicaAkAAdiz]

This was the most helpful video I've seen so far! Thank you!

[@ms.missylocs1584]

Great video right to the point explanation

[@saidiahussin3269]

The best video on 12 leads so far thanks doc i subbed

[@BestPracticeMedicine]

Thanks for the sub! Glad you liked it, stay tuned for more videos like this!

[@timjones3486]

saidia kzbin.info/www/bejne/qqa9n2lrjcqnb7M check this ECG video. It is very good.

[@saidiahussin3269]

@@timjones3486 thanks for the recommendations that one too is expressive

[@timjones3486]

saidia hussin thanks for getting back. I’m intrigued to know what you mean by to expressive? It’s only because I’m the author of that training video and any feed back about it is always helpful because I’m thinking about updating it.

[@dudebrah891]

I just had a ECG performed and I think the nurse did it wrong. While the test was going she was pushing down on some of the pads. And now there's some weird reading I now have to go see a specialist

[@FAT0MA9]

لقد أفادني جدًا في دراستي، شكرًا.

[@remiramo]

لو سمحتي هل تدرسي ekg technician program? ممكن تحكيلي عنها ..هل هي صعبة؟

[@heyho6469]

Now I’m confused. I was recently taught to follow the 5th intercostal for v6.

[@imwade3]

I know people that put the leg sticker bottom right or left above the hips or put the arm sticker before the shoulder (on the chest).

[@RichieV22]

Question: How did you identify the limb leads other than not too boney or in large muscle groups? Why not near the wrists or shoulders? (My apologies, if this is a dumb question. I’m just learning how to preform an ECG)

[@BestPracticeMedicine]

Limb leads require less exact of placement then leads 1-6. Some main steps to follow for the 4 limb leads are: 1. Make sure limb leads are symmetrical i.e. if the left is on the shoulder, the right one should be too. 2. Bony prominences/large muscles are not ideal placements for limb leads as they can cause artifact, harming the overall quality of the EKG. Hope these help Richard!

[@immaihedilionye920]

This is very much helpful. Thanks.

[@miahzTv]

How about locating the 4th intercoastal space in a female patient as a male doctor... How do you avoid making the patient feel embarrassed...

[@Honey1083]

Professionalism 😊

[@adnanraza5764]

Thank you so much.. I couldn’t find a better video than this one.

[@BestPracticeMedicine]

You're so welcome @adnan raza! So glad we could help. If there are any other specific topics you'd like to have us cover please let us know.

[@annetterobinson6326]

Awesome educational program. Thank you.

[@tybrady1935]

I just had an EKG and I see some mistakes that were done. I have some chest hair that was not shaved, I had my cell phone on my waist and I had a metal belt buckle on. Also, the cords were very tangled up, could that mess things up? I was sitting up almost straight, though my legs were elevated. My EKG showed I had a possible heart attack or it's an intraventricular conduction defect I was born with. The problem is that I cannot get an echo to determine if I had a MI for another three weeks!? I sure hope I had a false negative.

[@briannabradley6453]

hmmm V5 should be anterior axillary, along the same horizontal line as V4. Not mid way between V4 & V6.

[@jfisher1659]

Really well done and well described. Thank you!

[@lifeisbeautiful7464]

Thank you for this video 🤝🏽👌🏾👍🏾🤗

[@rajeshwarirao1944]

That was good..but you should have shown the front view while counting and placing the leads..first timers get a bit confused..Thanks

[@lib2574]

Does this help at all for HCB students?

[@pedroaortizmd7214]

Sure it's a good video, the quality of information are very good. The only error that I found and it should always be taken into account when taking an EKG, is that the patient should not wear, any metal object, in this case, the waist strap that has a metal part must be removed.

[@BestPracticeMedicine]

Thanks for watching Pedro! And we appreciate you keeping us sharp too. You are absolutely right about metal objects, as they can interfere with and cause artifact in 12-lead acquisition. Removing his belt is the best practice here.

[@ninaadsangeet4959]

Yes exactly

[@metrowash]

Great Video. Thanks so much!

[@simply.grace1]

Very helpful. Thank you, guys.

[@afnanahmedkarim5728]

12 leads! What about augmented leads aVL,aVR and aVF? Do limb leads (1 2 3) themselves act as both limb and augmented ones?

[@BestPracticeMedicine]

Short answer: yes. Limb leads 1-3 (RA, LA, and LL) function as bipolar and unipolar leads, the 3 unipolar leads created the augmented leads. In this way the 10 leads give 12 different views of the heart. Thanks for the question!

[@afnanahmedkarim5728]

@@BestPracticeMedicine thanks Regards ❤️

[@daanitzaa1]

V5 should be placed on the anterior axillary line!

[@thebestrelaxmeditation6682]

Hello sir , you explain very well . I just want to know where are the leads place if the patent amputee or if paraplegic . Thanks

[@BestPracticeMedicine]

Moving the 4 limb leads to the torso junctions where the limbs extend (or would extend from) is sufficient! Glad you liked it!

[@thebestrelaxmeditation6682]

@@BestPracticeMedicine thank you sir

[@margaretprawl313]

Thank you. Great video. Junior new RN

[@foijulamin3710]

Thanks for sharing your knowledge.lov you sir

[@ninaadsangeet4959]

Nice one sir🙌🏻

[@bonez1076]

Wait I didn't see him place the wires on the legs but good video

[@stephenortiz7659]

Thank you for this video !

[@moomoolaka]

thank you for the knowledge 🙏

[@quadruplelatte]

Great video!!

[@BestPracticeMedicine]

We are delighted you liked it Jody!

[@carmensumlin4294]

Well done!

[@toshmarley72]

Thank you for the video

[@BestPracticeMedicine]

No problem! We're glad to help

[@KarlaArredondo-f5d]

Thanks for the review

[@deborahbacchus7867]

Very informative.

[@BestPracticeMedicine]

Glad you appreciated the video!

[@Russianmedicohere]

They say 12 leads but they connected only 10

[@MalangBachaOfficial]

Thanks alot

[@seraphims2816]

what abt the belt, my ci said no metals

[@elizabethmensah3185]

Thank you so much

[@halipaelias9522]

Can't see your demo properly.

[@waywardgypsyqueen5766]

Super helpful!

[@BestPracticeMedicine]

Glad it was helpful!

[@ittakesavillage4517]

Thank you!

[@timjones3486]

This is a good video and well presented. I just wish you’d placed the arm electrodes on the wrists!

[@BestPracticeMedicine]

Hey Tim! Thanks for the comment and we are glad you enjoyed this video. As Loren states in the video 4-lead placement is less precise than V1-V6, and keeping them close to the torso often helps keep lead cords tidy throughout assessment. That being said, placing them on the wrists is definitely a viable option.

[@timjones3486]

Best Practice Medicine I must admit it does frustrate me when an attempt of performing an ECG with the electrodes placed slightly proximal to the wrists isn’t done first. We know that moving the arm electrodes away from the wrists towards the torso increases the r wave amplitude in the inferior lead, decreases the r wave amplitude in the lateral lead, causes a rightward shift in cardiac axis and alters the precordial amplitudes because of the effect to the central terminal. I strongly believe any training video should show wrist placement. I’ve performed12 lead ECGs in various situations over the years ranging from under lorries, front living rooms, dementia wards, cardiac wards etc and with good skin preparation rarely have had to move the electrodes from the wrists. Changing the filter from 150Hz to 40 Hz and documenting in clearly on a second ECG if a better option that having move the electrodes unless for example the patient has amputation or is combative. Anyway I still thought your video is far better that virtually all the other poor ones that are posted on KZbin so very well done.

[@chandanbiswas3910]

Beautiful

[@bobbysmith3196]

Great Job Fellas 👍👍👍 I’m relieved to find out that there may be absolutely nothing wrong with My Heart as… I just had an EKG done and the gal putting the electrodes or “leads” put all of them on my upper body 🤣🤣🤣 I knew it wasn’t correct (I ask about the two that’s supposed to go on-around my lower legs-they went on my upper hips) but she said it was Correct and would not even put two on my legs Nor my Arms-close to my wrist… The Person that’s responsible for the reading and comprehension of this EKG Says i have Sinus Rhythm Abnormal R-Wave Progression, Early Transition🤔🤔🤔 (ecg-ekg???) I’m curious as to the difference between these two types of Electrocardiograms… Going to try to find out more information on this Different types now… Again THANKS FOR THE VIDEO!!! You fellas may have saved me from having a Pacemaker Put In!!!🤣 Seriously though-makes me Wonder how many people have been diagnosed Wrong because of this one Procedure being performed Wrong… Always get a 2nd and maybe 3rd Opinion

[@elizabethkuchta5097]

I only see 10 leads?

[@mutated__donkey5840]

Why is it called a 12-lead ekg if there are only 10 leads used?

[@BestPracticeMedicine]

www.pngkey.com/png/detail/935-9350239_einthovens-triangle.png This is a great visual representation of why a 12-lead EKG only has 10 electrodes. Really your 4 limb leads create 6 different views of the heart by calculating a electronic center (usually around the AV node) creating leads aVF aVL and aVR. Hope this helps!

[@camilanham]

Beautiful lead placement! I see EMTs come through all the time with v1and 2 way up to the collarbones! I’m like 😬uhh no

[@emanuelfernandez98]

uhh EMTs arent certified for EKG so theyre probably just shitty paramedics

[@kylovich7129]

@@emanuelfernandez98 …..EMTs are absolutely allowed to set up an EKG. We aren’t allowed to officially read them. Setting up an EKG for our ALS partners is common practice for Basics. Also, I can’t imagine any paramedic getting their license if they placed V1 and V2 up by the collarbones… 🤦‍♂️

[@MkhululiNdlovumed]

48Bpm: too low. Is it for real?

[@definitelyaerobloc285]

why are those T waves huge

[@MichalPrzyb723]

On miał arytmie???

[@nkechiprincewillodum868]

Thanks, well explained.

[@lems18902]

Did anyone notice his heart rate was in the 40s?

[@BestPracticeMedicine]

Good catch! The best providers remain calm, cool, and collected (even when they are shirtless on camera :D)

[@sigrid27]

He must have a runner’s heart rate. He was also in the Semi Fowler’s position. Upright the hr will be a little higher once he starts moving. As long as at rest, the BP isn't high in contrast it is most likely his normal.

[@pedroaortizmd7214]

Usually, this type of healthy athletic patients, like the one shown in the video, manages a normal sinus rhythm, but the heart rate in athletes is usually lower, than the cedental person. It is important to know if it was a routine study, or in this case the patient's bradycardia was being studied.

[@MichalPrzyb723]

znaczna bradykardia zatokowa z arytmią zatokową ten Pan ma.

[@nathanialcopeland7032]

ALSO DONT FORGET SMOKE OVER FIRE IN ECG

[@Kim-pj9us]

Where brown,black, purple?

[@Mrk12329]

Kmu IHS mardan students reply KRY

[@SavannahWilson-fb9zl]

watch it

[@StrongMonica-v2b]

Clark Kenneth Perez Richard Hall Timothy

[@PoeJanice]

Moore Robert Martinez Daniel Lee Patricia

[@estefanydcastillo]

Would it be possible to do this with a girl? I know it might be different considering there is going to be a boob in the way. If it is possible, thank you so much!

[@j.elliottcole9506]

You need to lift the boob up. Dont apply electrodes to boobs.

[@ZoeJohnston-k8o]

Wilson Shirley Martinez Timothy Martinez Melissa

[@thelordofliesween540]

Don’t need guests when you have these 3 at maximum performance

[@ElsieDixon-o2e]

Clark Donna Lopez Amy Lopez Ronald

[@rfcalm]

no need for the music. Doesn't add anything. If anything, it distracts from the message. Other than that, thanks for the presentation

[@MelissaGrahamgy]

Clark Margaret White Jose Williams Eric

[@TeriHamilton-o4e]

Gonzalez Edward Harris Nancy Clark Daniel

[@LorenaGraves-j7b]

Lopez Frank Young Barbara Davis Daniel

[@ThomasButlergT6]

Brown Larry Johnson Edward Harris Eric

[@RohitSormaes]

Robinson Betty Lee Linda Anderson Melissa

[@StudentsThough]

Harris John Lewis Kenneth Miller Sandra

[@MelissaTurberville-p3o]

Perez Laura Taylor Thomas Wilson Laura

[@GajshAksjb-y3l]

Williams Laura Garcia Sharon Lewis Dorothy

[@LorenaGraves-j7b]

Hall Jessica Johnson Donna Lewis Susan

[@germinehenein3473]

Hi l) U

[@AjidaHasan]

White Kimberly Robinson Kimberly Wilson Mary

[@KWhite-f5e]

Wilson Brian Rodriguez Patricia Wilson Brenda

[@CommonsAnsel-s9z]

Lewis Anthony Young Richard Gonzalez Laura

[@HiknbfunnyHkkgg]

Anderson Sandra Rodriguez Frank Wilson Jessica

[@pauleedavidson9251]

Moore Charles Williams Ruth Young Jose

[@pauleedavidson9251]

Jones Melissa Martin Patricia Moore Carol