ELECTROCARDIOGRAM:

12 LEADS
Ms. Shyluck May D. Diong-an
Senior Specialist Nurse
Clinical Instructor, CCL
WHAT IS
ELECTROCARDIOGRAM?

 Records the electrical activity of the heart through specialized

terminals called electrodes that are placed at distinct locations on the
human body surface. Currents are transmitted and recorded based on
the location of these electrodes and the relationships that are created
between them.
 The ECG depicts the direction of energy flow through the heart. This
electrical cascade begins with stimulation of the individual myocytes
and continues on through specialized areas of conducting cells that
create the sinus node, atrioventricular (AV) node, bundle of His and
the bundle branches.
INDICATIONS OF ECG
 Chest pain or suspected myocardial infarction (heart attack),
such as ST elevated myocardial infarction (STEMI) or non-ST
elevated myocardial infarction (NSTEMI)
 Symptoms such as shortness of breath, murmurs,
fainting, seizures, funny turns, or arrhythmias including new
onset palpitations or monitoring of known cardiac arrhythmias
 Medication monitoring (e.g., drug-induced QT
prolongation, Digoxin toxicity) and management of overdose
(e.g., tricyclic overdose)
 Electrolyte abnormalities, such as hyperkalemia
INDICATIONS OF ECG
 Perioperative monitoring in which any form of anesthesia is
involved (e.g., monitored anesthesia care, general anesthesia).
 Cardiac stress testing
 Computed tomography angiography (CTA) and magnetic
resonance angiography (MRA) of the heart (ECG is used to
"gate" the scanning so that the anatomical position of the heart
is steady)
 Clinical cardiac electrophysiology, in which a catheter is
inserted through the femoral vein and can have several
electrodes along its length to record the direction of electrical
activity from within the heart.
ELECTROCARDIOGRAM
 Left sided ECG – Standard ECG
 Right sided ECG –
 To diagnose or rule out Right ventricular infarction
 Dextrocardia patients
 Posterior ECG –
 To diagnose or rule out Posterior wall myocardial infarction
Why 12 Lead ECG Have
10 Wires/Connectors?
Limb Leads Augmented Vectors Chest Leads
 ANATOMY OF 12-LEAD ECG

12 Leads
● 3 bipolar limb leads – I, II, III
● 3 augmented limb leads – aVR, aVL, aVF
● 6 precordial (chest) leads – V₁, V₂, V₃, V₄, V₅,
V₆
10 electrodes
● RA, LA, LA, LL
● 6 chest electrodes
BIPOLAR LIMB LEADS

● Lead I – Lateral wall of the LV

● Lead II – Inferior wall of the heart
● Lead III – Inferior wall of the heart

EINTHOVEN TRIANGLE
AUGMENTED LIMB LEADS
● aVR – RV, basal septum
● aVL – high lateral wall of LV
● aVF – inferior wall of the heart
UNIPOLAR CHEST LEADS

● V₁ - V₂ - Septal wall of the heart

● V₃ - V₄ - Anterior wall of the heart
● V₅ - V₆ - Lateral wall of the heart
 EGC LEAD PLACEMENT PREPARATION

Site preparation and ECG electrode placement directly impact

the quality of an ECG signal. Optimizing an ECG signal is
imperative for accurate monitoring.

The processes involved in successful lead placement include:

• Skin Preparation
• Electrode Patches
• Lead Placement Methods: AHA
SKIN PREPARATION
Proper skin preparation is essential to obtain accurate ECG data. Electrode sites
should be clean, dry and should provide a smooth flat surface. Incidental
electrical activity and inaccurate readings may occur due to incorrect skin
preparation.
The following skin preparation is recommended for secure patch application:
 Wash the skin with soap and water, then dry with gauze pads or washcloth.
 Clip the chest hair in a 2-4 inch diameter of the electrode site.
 Use a dry gauze pad to remove excess skin oils, skin cells and residue from
the electrode sites. Never rub the skin until it is raw or bleeding.

NOTE: Prepare the electrode site with alcohol only if the skin is extremely
greasy. If alcohol is used as a drying agent, always allow the skin to dry before
placing the electrode patch on the skin.
ELECTRODE PATCHES

NOTE: Store electrode patches at room temperature in a sealed package

until just prior to use.

NOTE: Avoid more than one type of electrode on a patient because of

variations in electrical resistance.

NOTE: Avoid placing electrode patches directly over boney prominences or

over any areas that move during activity such as shoulders or arms because
muscle motion produces electrical activity. If an electrode patch is placed
over a large muscle such as the pectorals, the monitor may detect this
additional muscle activity which could lead to false arrhythmia calls.
 PREPARE THE ELECTRODE

1. Peel the backing off of the electrode patch only when it is ready for use to prevent
evaporation of the contact gel medium. Visually inspect the contact gel medium for
moistness. If the gel medium is not moist, do not use the electrode patch. Dry electrode
patches are not conductive.
NOTE: If using the snap type electrode wires, attach the electrode patch to the lead wire
before placing patch on the patient.
2. Attach the electrode patch to the skin at the prepared site. Smooth the electrode
patch down in a circular motion to ensure proper skin contact. If using soft gel
electrodes, never push down directly over the contact gel medium as this may displace
the gel and cause monitoring artifact. If using hard gel electrodes, it is recommended
that during application, the center of the electrode should be slightly pressed onto the
skin to ensure direct contact. Consult the electrode patch manufacturer’s instructions for
specific use.
LEAD PLACEMENT METHOD

The lead placement procedure that is utilized has a direct

impact on the quality of an ECG waveform.
ECG electrode placement is standardized, allowing for the
recording of an accurate trace, but also ensuring comparability
between records taken at different times.
Poor electrode placement can result in mistaken interpretation,
which may lead to possible misdiagnosis, patient
mismanagement or inappropriate procedures
ECG: limb leads
 Limb leads are made up of 4
leads placed on the
extremities:
 left and right wrist;
 left and right ankle
 Neutral lead- the lead
connected to the right ankle.
 It is there to complete an
electrical circuit and plays no
role in the ECG itself.
ECG: limb leads placement
o Connect the lead wires to the
electrodes. The tip of each lead wire is
lettered and color coded for easy
identification.
o The RED or RA lead wires goes to the
right arm
o The YELLOW or LA lead wire goes to the
left arm
o The BLACK or N/RL lead wire goes to
the right leg
o The GREEN or LL lead wire goes to the
left leg
ECG: precordial/chest leads

 V1: 4th intercostal space (ICS), RIGHT margin of the

sternum
 V2: 4th ICS along the LEFT margin of the sternum
 V4: 5th ICS, mid-clavicular line
 V3: midway between V2 and V4
 V5: 5th ICS, anterior axillary line
(same level as V4)
 V6: 5th ICS, mid-axillary line
(same level as V4)
ICS – intercostal space
Right Sided ECG Electrode Placement

 There are several approaches to

recording a right-sided ECG:
 A complete set of right-sided leads is
obtained by placing leads V1-6 in a
mirror-image position on the right side of
the chest (see diagram)
 It can be simpler to leave V1 and V2 in
their usual positions and just transfer
leads V3-6 to the right side of the chest
(i.e. V3R to V6R).
 Cont.
 The most useful lead is V4R, which is
obtained by placing the V4 electrode
in the 5th right intercostal space in the

mid-clavicular line.
 ST elevation in V4R has a sensitivity
of 88%, specificity of 78% and diagnostic
accuracy of 83% in the diagnosis of RV
MI.
The LIMB lead will be in same position
as the standard ECG.
 ECG: Posterior Leads

 ST elevation greater than 0.5mm in leads

V7- V9 is a diagnostic of Posterior Wall MI
Tips for recording Posterior ECG
 Arm and leg electrodes remain unchanged
 Take the chest leads V4, V5 and V6
 Leads V7- V9 are placed on the posterior
chest wall in the following positions:
TIPS: If you don’t have the access to a 15 or 18 lead ECG machine, then
leave V1 to V3 in their normal position and use V4, V5 and V6, these
leads will then become V7, V8 and V9
• Do not FORGET to label the ECG paper and posterior ECG

V7 – (which was the V4) Left

posterior axillary line, in the
same horizontal plane as V6.
V8 – (which was the V5) Tip of
the left scapula, in the same
horizontal plane as V6.
V9 – (which was the V6) Left
paraspinal region, in the same
horizontal plane as V6.
ECG ARTIFACTS

An ECG artifact is used to indicate something that is not

"heart-made."
These include (but are not limited to) electrical
interference by outside sources, electrical noise from
elsewhere in the body, poor contact, and machine
malfunction.
Artifacts are extremely common, and knowledge of them is
necessary to prevent misinterpretation of a heart's
rhythm.
 REVERSE LEADS/MISPLACED ELECTRODES
Electrode/lead placement is very important. If
one were to accidentally confuse the red and
white lead cables (i.e. place the white one where
the red one should go, vice versa), he might get
an ECG that looks like this. In this ECG, we can
make out a normal sinus rhythm with all of the
waves upside-down. When this happens, you
are essentially viewing the rhythm in a
completely different lead.
AC INTERFERENCE

 Alternating current (AC) describes the type of

electricity that we get from the wall. In the United
States, the electricity "changes direction" 60 times
per second (i.e. 60 hertz). (Many places in Europe
use 50 Hz AC electricity.)
 When an ECG machine is poorly grounded or not
equipped to filter out this interference, you can get
a thick looking ECG line. If one were to look at this
ECG line closely, he would see 60 up-and-down wave
pattern in a given second (25 squares).
MUSCLE TREMOR/NOISE

 The heart is not the only thing in the body that

produces measurable electricity. When your
skeletal muscles undergo tremors, the ECG is
bombarded with seemingly random activity. The
term noise does not refer to sound but rather to
electrical interference.
 Low amplitude muscle tremor noise can mimic
the baseline seen in atrial fibrillation.
 WANDERING BASELINE

In wandering baseline, the isoelectric line changes

position. One possible cause is the cables moving
during the reading. Patient movement, dirty lead
wires/electrodes, loose electrodes, and a variety of
other things can cause this as well.