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ONTARIO BASE HOSPITAL GROUP Chapter 7 for 12 Lead Training -AcquisitionOntario Base Hospital Group Education Subcommittee 2008 TIME IS MUSCLE Acquisition AUTHOR REVIEWERS/CONTRIBUTORS Greg Soto, BEd, BA, ACP Neil Freckleton, AEMCA, ACP Hamilton Base Hospital Niagara Base Hospital Jim Scott, AEMCA, PCP Sault Area Hospital Ed Ouston, AEMCA, ACP Ottawa Base Hospital Laura McCleary, AEMCA, ACP SOCPC Tim Dodd, AEMCA, ACP Hamilton Base Hospital 2008 Ontario Base Hospital Group Dr. Rick Verbeek, Medical Director SOCPC OBHG Education Subcommittee Chapter 7 Objectives Identify the goals for acquiring 12 Lead ECG Describe differences between 3-Lead & 12Lead ECG Locate placement of limb & chest leads Explain causes of artifact and list remedies Describe dignity issues involved in exposing chest and list solutions OBHG Education Subcommittee Acquisition Does NOT have to increase scene time PHECG studies have found on scene times to increase minimally (0 - 3 minutes) Scene time with PHECG improves with practice and scene organization OBHG Education Subcommittee Acquisition Goals Clear Accurate Fast OBHG Education Subcommittee 12 Lead ECG Not just some extra wires Very different internal design due to filters OBHG Education Subcommittee 3-Lead ECG Monitor Quality OBHG Education Subcommittee 12-Lead ECG Diagnostic Quality OBHG Education Subcommittee Diagnostic Quality Produces more accurate ST segments and T waves More sensitive to artifact OBHG Education Subcommittee Diagnostic Quality You may have to take steps to improve ECG quality. More on this later OBHG Education Subcommittee Leads Limb Leads I, II, III AVR, AVL, AVF Precordial Chest Leads V1, V2 V3, V4 V5, V6 OBHG Education Subcommittee Lead Placement Lead placement is critical If not placed correctly (even by one interspace) the resulting ECG will exhibit changes that could be misconstrued as “abnormal” and profoundly affect patient care OBHG Education Subcommittee Limb Lead Placement Place leads on limbs Away from major muscles or arteries Have patient remain still during 12 lead acquisition (to reduce artifact) OBHG Education Subcommittee Limb Lead Placement Place electrodes on the limbs if there is a 12 lead in the patient’s future – highly preferable to torso placement OBHG Education Subcommittee Limb Lead Placement Reasons to place on the torso? Fracture Amputation Artifact If Limb Leads are placed on the torso make sure to document this directly on the 12 Lead ECG OBHG Education Subcommittee Limb Leads aVR should be negative If aVR is upright, check for reversed limb leads OBHG Education Subcommittee Precordial Chest Leads For every person, each precordial lead placed in the same relative position - 4th intercostal space, R of sternum V2 - 4th intercostal space, L of sternum V4 - 5th intercostal space, midclavicular V3 - between V2 and V4, on 5th rib or in 5th intercostal space V5 - 5th intercostal space, anterior axillary line V6 - 5th intercostal space, mid-axillary V1 OBHG Education Subcommittee Chest Lead Placement OBHG Education Subcommittee Chest Lead Placement V1 is placed in the 4th intercostal space to the right of the sternal boarder To find the 4th intercostal space feel for the clavicle Just below the clavicle is the 2nd rib, then 3rd and 4th rib Between the 4th rib and the 5th rib is the 4th intercostal space V2 is placed to the left of the sternal boarder in the 4th intercostal space OBHG Education Subcommittee Chest Lead Placement V4 is placed next in the 5th intercostal space in the mid-clavicular line Find the half way mark on the left clavicle and move down one rib so V4 is between the 5th and 6th ribs V3 is placed after V4 and is simply placed in between V2 and V4 either on the 5th rib or in the 5th intercostal space OBHG Education Subcommittee Chest Lead Placement V5 is placed in the 5th intercostal space and the anterior axillary line To find the anterior axillary line lay the patient’s left arm at their side and follow the crease line in their armpit down the front of their chest V6 is placed in the 5th intercostal space in the mid-axillary line OBHG Education Subcommittee Chest Lead Placement V1 V2 V3 V4 V5 V6 V1: 4th intercostal space to the right of the sternum V2: 4th intercostal space to the left of the sternum V3: directly between V2 and V4 V4: 5th intercostal space at the left mid-clavicular line V5: level with V4 at the anterior axillary line V6: level with V5 at the mid-axillary line OBHG Education Subcommittee Exposing the Chest & Pt Dignity Where required: Remove clothing only if necessary Replace with a gown or a sheet With practice: Chest leads can be placed on adult women without exposing breasts Work around bras where prudent When placing electrode for V4, use the back of a gloved hand to lift a women’s left breast AFTER informing her. It is difficult to construe this action as sexual contact vs. using the front of a cupped hand. OBHG Education Subcommittee Video - Acquisition Play 12 Lead ECG Acquisition video here OBHG Education Subcommittee Reduce Artifact: Skin Prep Dry moist skin Clip or shave excess hair Abrade dead skin with skin prep tape, plastic backing of 12 lead stickers or dry 4x4 gauze OBHG Education Subcommittee Other Causes of Artifact Patient Cable movement movement Vehicle movement Electro-Magnetic Interference OBHG Education Subcommittee Patient Movement Make patient as comfortable as possible: Supine preferred Sitting most common with chest pain/SOB patients OBHG Education Subcommittee Patient Movement Check Toe Look for subtle movement: tapping, shivering for muscle tension: Hand grasping rail, head raised to “watch” Coach the patient: Lie still, stop talking, breath slow and quiet OBHG Education Subcommittee Cable Movement Some “slack” between monitor and patient is needed Not too much “slack” (leads can come off electrodes) OBHG Education Subcommittee EMI Electro-Magnetic Interference EMI can interfere with electronic equipment: Airlines prohibit use of electronic equipment during take-off OBHG Education Subcommittee EMI Maintain awareness of possible EMI interference: Cell phones Radios Most electrical devices Fluorescent lights OBHG Education Subcommittee Clear ECG Things to look for… Little or no artifact Steady baseline Which is worse for reading 12 Lead ECG? OBHG Education Subcommittee Oh Oh!! Now What? OBHG Education Subcommittee Ahhh! Much Better Note: the baseline straightened out by simply repositioning the patient cables and clipping them onto the sheet. OBHG Education Subcommittee ONTARIO BASE HOSPITAL GROUP QUESTIONS? ONTARIO BASE HOSPITAL GROUP Well Done! Education Subcommittee START QUIT