How to obtain a 12-lead ECG with proper electrode placement and excellent data quality

Tom Bouthillet demonstrates how to obtain a 12-lead ECG with accurate electrode placement and excellent data quality while visiting Dearborn Fire Department.
#12LeadECG #Electrocardiography #EMS #LeadPlacement #ACLS

[@EMSQuality]

Tom, Do you have any tips about skin preparation - shaving, diaphoresis, shivering, etc. - to get a cleaner baseline (i.e., isoelectric line)?

[@TomBouthillet]

Our ambulances carry electric body hair razors and tincture of benzoin can be a big help if the patient is diaphoretic. If a patient is shivering or experiencing tremors you can lay several blankets down on top of the patient which seems to help. Some folks like to use a mild abrasion technique using a fine sandpaper like the 3M Red Dot Trace Prep. The science convincingly shows this makes a difference with the signal although I confess it's not something that I have done very often.

[@cantlieman]

As a woman, thankyou for being so kind and considerate. Also, if a female medical professional is present it would be easier for you guys to navigate the situation.

[@TomBouthillet]

There have been several occasions where having a female crew member would have been ideal.

[@davidmlacombe]

Nice tutorial, Tom. I like the conversational tone and practical tips.

[@TomBouthillet]

Thanks, David!

[@alialyaseri6789]

Nice presentation I wish to see more like that with practical tips on different issues in EM, CV & acute care topics. Regards

[@tbip2001]

Also one thing for sure, make sure you have s Consistent lead placement . If you use wrist/ankles in the house, ensure you cotinue wiiith those placings in the house as moving to torso or even upper arm can cause drastic changes as another comme term has said. I made that mistake once and it resulted in flipped t waves which I interperated as an ecg change over time. .

[@jmiheve]

Nice quick tutorial! The only thing I would have liked to see was a quick mention about why putting limb leads on the limbs is so important (i.e., torso placement can mask an MI or cause a false positive).

[@TomBouthillet]

Good point! The decision to activate the cardiac cath lab often comes down to a fraction of a millimeter. I am aware of one case where placing the limb leads on the torso led to a flipped T-wave in lead aVL in a patient with early repolarization in the inferior leads that led to a false positive *** ACUTE MI SUSPECTED *** message from the computerized algorithm. Fortunately, the attending physician in the ED slowed things down. By following a standard we have a better chance of a successful "apples to apples" comparison to the old ECG in the patient's chart.

[@gabrielgunning6006]

yeah perhaps you could do follow up on interesting little pearls of STEMI rescue? lvh bbb hyperkalemia hypothermia etc - your presence and quietly professional demeanor is a wonderful role model for future medics - we are eagerly anticipating your next vlog up here in good ol’ Wicked Cold Maine!

[@TomBouthillet]

@@gabrielgunning6006 That's very kind of you! Thanks, bother. Not to worry. My intent is to create many more videos covering all of those topics and more.

[@gabrielgunning6006]

Tom Tom Bouthillet i suspected as much - will be standing by to standby!

[@jj5282]

Thank you so much!

[@TomBouthillet]

You're welcome!

[@LoveEmmanuella00]

Interesting

[@Thenotfunnyperson]

Well done

[@TomBouthillet]

Thank you!

[@sydharrison]

I was realllllly hoping to hear some tricks of the trades regarding how to prevent artifact while performing 12L's. I have found a consistent amount of artifact when using LP15 across several of my departments that I oversee. Any tips found that has improved this. They are placing the leads appropriately and performing then at a standstill. any advice is welcome!

[@TomBouthillet]

I have not found a particular issue with LP12 or LP15. Obtaining prehospital 12-lead ECGs with excellent data quality is a challenge for all EMS systems. It requires a lot of time, attention, and monitoring. Personally, I feel like I give good advice in this video, although I also wrote an article about ECG artifact here: www.aclsmedicaltraining.com/blog/guide-to-understanding-ecg-artifact/

[@tbip2001]

How do you deal with a pt with a tremor. Traditionaly we have placed limb leads on the wrist and ankles. We can place further up the arm as shown here but tremor can sometimes still be a problem. Is torso placement ever warranted?

[@TomBouthillet]

There are times (like cardiac stress testing) where limb lead placement on the torso using a validated technique like the Mason-Likar is warranted. To deal with tremors we have found that using multiple blankets over the leads can be helpful. Thanks for the comment!

[@yogichester9143]

Hello I have a question I was in a car accident & abandoned at the time of the car accident the ambulance arrived I was told my heart was beating super slow , do you know if they had to put narc spray up my nose ? & I also woke up with ECGs on me & I was connected to A IV machine as well in THE emergent hall way

[@TomBouthillet]

Hi, Yogi! If you want to know what happened on the emergency call, bring your ID to EMS HQ and ask for a copy of the run report. It’s impossible for me to comment on your clinical condition at the time. Good luck!

[@ktthompson1471]

Is it painful?? I have an ekg i need to do on may 18

[@TomBouthillet]

It’s just stickers. You should be just fine!

[@michaelpamintuan7855]

With all due respect to people who are Hairy, if u want accurate reading, WE WILL SHAVE YOU 😂

[@zingoringo4656]

Can take it while ambulane run?! Or should stop it!!

[@TomBouthillet]

Hopefully, you'd have already obtained one on scene. But yes, I would record serial ECGs en route to the hospital, as needed.

[@zingoringo4656]

@@TomBouthillet thank you sir

[@TomBouthillet]

@@zingoringo4656 You bet!

[@dtf007]

I can think of at least three ways the dog could have been included.

[@TomBouthillet]

I'll be sure to add Ginger to the production schedule when the time is right.

[@schatz1876]

Question: When a woman has large breasts, first of all does she keep her bra on ? and secondly do the leads go under the breast ?

[@TomBouthillet]

You can find references in the medical literature for electrodes being placed on top of large, pendulous breasts, in the correct anatomical position. However, as a practical matter, we place them under the breasts. I once placed the electrodes for V3-V5 on a patient's large, pendulous left breast, and it upset a nurse in the Emergency Department. So, like anything else, the approach should be standardized within a given system of care. As for whether or not to remove a bra, I would at least ask the patient to unclasp it. Sometimes patients don't mind being exposed and others are more modest. Ask for consent and explain what you'd like to do, and then respect the patient's boundaries. It's often easiest to have the patient lift up her own left breast while you apply electrodes. If you are touching a patient's breast, with permission, use the back of a gloved hand.

[@schatz1876]

@@TomBouthillet thank you for responding

[@traumajock]

"appears to be a male" :)~~~~ Medtronic bettah add a non-gender specific option!

[@TomBouthillet]

You know, the LP12 didn't make you select a gender so I wasn't prepared! ☺

[@cantlieman]

Any rational person and especially a medical professional should know absolutely whether the patient is male or female.