12 and 15 Lead Acquisition

STEMI Recognition Class

12 Lead Rapid Acquisition

• Module 1 Electrode Location

• Module 2 Electrode Placement

• Module 3 How to do a 15 Lead

• Module 4 Demonstrations

• Module 5 Reducing Artifact

• Module 6 Tips and Techniques

Module 1 Electrode Location

Electrodes must be placed in the proper position to obtain an accurate 12 Lead ECG

Module 1 Electrode Location

12 leads obtained from 10 electrodes

• 4 on the limbs

• 6 on the chest

Module 1 Electrode Location

Limb lead positioning is simple.

The electrodes are placed off the torso, on the limbs. The most correct positioning is near the wrist and ankles.

However, EMS generally places the electrodes on/near the torso to limit artifact while transporting.

Module 1 Electrode Location

Chest leads have specific anatomic locations

V1, V2, V4 the rest are placed in relationship to these leads

Module 1 Electrode Location

Module 1 Electrode Location

Module 1 Electrode Location

Module 1 Electrode Location

Module 1 Electrode Location

Module 1 Electrode Location

Module 1 Electrode Location

Module 1 Electrode Location

Module 2 Electrode Placement

• The key to correctly placing the chest electrodes is finding the 4th intercostal space

Module 2 Electrode Placement

Module 2 Electrode Placement

Module 2 Electrode Placement

Here’s another approach to locating the 4th intercostal space

Module 2 Electrode Placement

Best view laterally

Module 2 Electrode Placement

1• Locate the supersternal

notch (1) at the top of the manubrium

• Palpate down appox 2” until you find the sternal angle, slide your finger laterally to the right, you’re finger is now on the 2nd rib

• Palpate down into the 2nd 3rd and 4th intercostal space

Module 2 Electrode Placement

After placing V2, palpated down to the 5th intercostal space midclavicular line and place V4

Module 2 Electrode Placement

V1 V2V3V4V4R

15 Leads are simple

Remove V4 and move it 5th intercostal space,

midclivicular on the Right side of Pt’s

chest

Module 2 Electrode Placement

15 Leads are simple

Remove V4 and move it 5th intercostal space, midclavicular on the

Right side of Pt’s chest

Module 2 Electrode Placement

Module 2 Electrode Placement

Module 2 Electrode Placement

Module 2 Electrode Placement

Module 2 Electrode Placement

Module 2 Electrode Placement

Module 2 Electrode Placement

Module 2 Electrode Placement

Module 2 Electrode Placement

Module 3 Demonstrations

Module 3 Demonstrations

Module 3 Demonstrations

Module 3 Demonstrations

Module 3 Demonstrations

Module 3 Demonstrations

Module 3 Demonstrations

Module 3 Demonstrations

Module 3 Demonstrations

Module 3 Demonstrations

Module 3 Demonstrations

If you were the patient, where would you prefer to have you’re 12 Lead done, in the house or in the truck?

Module 3 Demonstrations

There’s a lot of people out there and they can see into the ambulance. You should obtain the 12 lead in

the house

Module 3 Demonstrations

Module 3 Demonstrations

Module 3 Demonstrations

Module 3 Demonstrations

Module 3 Demonstrations

Module 3 Demonstrations

Module 3 Demonstrations

Module 3 Demonstrations

Module 3 Demonstrations

Practice Time

Module 4 Reducing Artifact

Unless you have a clear ECG to analyze, all you interruptive skills are of little use

Module 4 Reducing Artifact

Stress labs obtain clear ECG’s while the Patient is running on a treadmill

We should be able to obtain a 12 lead while the Patient is laying still

Module 4 Reducing Artifact

As the heart depolarizes, an electrode on the Pt’s skin picks up the electrical activity

Module 4 Reducing Artifact

It can also pick up other electrical signals

Module 4 Reducing Artifact

To reduce artifact, we have to increase the heart’s signal and reduce the other electrical activity

Module 4 Reducing Artifact

Artifact Reduction Strategy:

Helping the electrode gel to better penetrate the skin will increase the signal strength from the heart and reduce the signal strength from other sources.

Module 4 Reducing Artifact

Module 4 Reducing Artifact

Remove hair with electric clippers

Module 4 Reducing Artifact

Module 4 Reducing Artifact

Now the skin is prepared, we can attach our electrodes

Module 4 Reducing Artifact

Module 4 Reducing Artifact

Module 5 Tips and Techniques

Supine is the proper position, if the Pt will tollerate

Module 5 Tips and Techniques

When the Pt changes position, the heart moves within the chest. This can cause ECG changes

similar to a misplaced electrode.

Module 5 Tips and Techniques

Do your best to maintain the modesty of a female Pt

Module 5 Tips and Techniques

You could try wide medical tape

Module 5 Tips and Techniques

A folded blanket or towel may help hold the electrodes in place

Module 5 Tips and Techniques

• Strand each lead out individually

• When ECG cables are looped around IV lines, O2 tubing, BP cuff tubing, or dangling between squad bench and stretcher you will have more artifact

• Make sure the Pt isn’t twiddling the ECG cables

• If unable to lay supine for ECG, place them semi-fowlers and breathing normally

• Do not allow Pt to prop themselves up by the arms or you will have muscle tremor artifact

Module 5 Tips and Techniques

• If the Pt is cold/shivering, cover with blanket or sheet prior to capturing the 12 Lead

Module 5 Tips and Techniques

Same Pt as before, covered with a towel

Module 5 Tips and Techniques

For some Pt’s obtaining a clear ECG will be difficult (e.g. respiratory distress Pt, sitting up)

However, in most cases it is possible to a 12 Lead ECG with excellent, or at least acceptable data quality

It just takes effort. A desire to obtain a clean 12 Lead and the knowledge to trouble shoot problems

Module 5 Tips and Techniques

Myocardial Infarctions are not like broken bones, and therefore, ECG’s are not like X-rays.

If you’re treating a Pt with a broken hip. That x-ray could be taken now, 10 min’s from now, an hour from now and what would you see? A broken hip.

With MI the events in the coronary artery can be changing moment by moment. The ECG can be very dynamic as well.

There is a value to obtaining repeat ECG’s when you suspect MI. Making a habit of doing early and repeat ECG’s will help you identify a STEMI that could easily be missed.

Module 5 Tips and Techniques

Module 5 Tips and Techniques

12 lead Validation

Does Lead I show Global Negativity?

12 lead Validation

Limb Reversal!

12 lead Validation

Look for R Wave Progression in the pre-cordial leads. The QRS should go from negative to more positive.

Validate this 12 lead

Module 5 Tips and Techniques

This short course provides you with what you need to know in order to rapidly obtain a 12 Lead ECG that’s both clear and accurate

Just as the case with ECG interpretation, acquisition also requires practice. After you’ve done this 20 or 30 times, you’ll become comfortable and confident

FIN