Transcript Slide 1
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
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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
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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
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Acquisition Goals
Clear
Accurate
Fast
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12 Lead ECG
Not
just some extra wires
Very
different internal
design due to filters
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3-Lead ECG
Monitor
Quality
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12-Lead ECG
Diagnostic
Quality
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Diagnostic Quality
Produces
more accurate ST
segments and T waves
More
sensitive to artifact
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Diagnostic Quality
You
may have to take
steps to improve ECG
quality.
More on this later
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Leads
Limb Leads
I, II, III
AVR, AVL, AVF
Precordial Chest
Leads
V1, V2
V3, V4
V5, V6
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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
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Limb Lead Placement
Place
leads on
limbs
Away from major
muscles or arteries
Have patient
remain still during
12 lead acquisition
(to reduce artifact)
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Limb Lead Placement
Place
electrodes
on the limbs if
there is a 12 lead
in the patient’s
future – highly
preferable to torso
placement
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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
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Limb Leads
aVR
should be negative
If
aVR is upright, check for
reversed limb leads
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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
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Chest Lead Placement
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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
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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
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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
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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
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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.
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Video - Acquisition
Play 12 Lead ECG Acquisition
video here
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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
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Other Causes of Artifact
Patient
Cable
movement
movement
Vehicle
movement
Electro-Magnetic
Interference
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Patient Movement
Make
patient as
comfortable as possible:
Supine
preferred
Sitting most common with
chest pain/SOB patients
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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
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Cable Movement
Some
“slack” between monitor
and patient is needed
Not
too much “slack” (leads can
come off electrodes)
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EMI
Electro-Magnetic
Interference
EMI
can interfere with electronic
equipment:
Airlines
prohibit use of electronic
equipment during take-off
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EMI
Maintain
awareness of possible
EMI interference:
Cell phones
Radios
Most electrical devices
Fluorescent lights
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Clear ECG
Things to look for…
Little
or no artifact
Steady baseline
Which is worse for
reading 12 Lead ECG?
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Oh Oh!! Now What?
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Ahhh! Much Better
Note: the baseline straightened out by
simply repositioning the patient cables
and clipping them onto the sheet.
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ONTARIO
BASE HOSPITAL GROUP
QUESTIONS?
ONTARIO
BASE HOSPITAL GROUP
Well Done!
Education Subcommittee
START
QUIT