Emt

The LA and RA limb leads are placed on the wrists (alternatively the
deltoid area). The LL and RL limb leads are place near the ankles - over
muscle not bone (alternatively both can be placed side by side on the left
lower leg). The incorrect placement of the limb leads (RA, LA, RL and LL)
on the torso will result in a non-standard 12-lead with the potential for
false positives and negatives.

Snug connection points, wire alignment, and reduced pulling or tension on

the 12-lead wires and cable are important in helping to reduce poor data
quality (noise). The wires should not cross each other.

The six precordial (chest) leads are placed at very specific locations.
Proper electrode placement and preparation are critical for accurate 12-
lead diagnostics. The Angle of Louis, which is anatomically adjacent to the
second rib, is a key landmark for locating the fourth and fifth intercostal
spaces. Always use your fingers when determining electrode site
locations.

Precordial Lead Electrode Placement:

V1 Fourth intercostal space to the right of the sternum

V2 Fourth intercostal space to the left of the sternum

V3 Directly between leads V2 and V4

V4 Fifth intercostal space at the midclavicular line

V5 Level with V4 at the left anterior axillary line

V6 Level with V5 at the left midaxillary line

Best Practice
 Always shave hair at electrode site. Ensure that the electrode site is
dry (use an alcohol pad on sweaty skin). To increase gel conduction,
briskly rub the skin area with a non-sterile gauze pad (removes
sweat, oils and dead skin cells).

 Electrodes are from a package that is sealed from the air; ensure
that the date code of the electrodes is not expired.

 Apply the electrodes to the lead wires before applying to the

patient’s skin.

 Grasp electrode tab and peel electrode from carrier.

 Inspect the electrode gel to ensure that the gel is intact; discard and
replace the electrode if necessary.

 Apply electrode flat on the skin and avoid pressing the center of the
electrode. Press around the outer perimeter of the electrode to
ensure full adhesion.

 The patient needs to be fully supported and at rest, preferably

supine or at a 30 degree angle; expose the chest area.

 Find the second rib by locating the Angle of Louis. To do this, place
your finger in the notch at the top of the sternum and slowly move
your fingers downwards, about 4 centimeters, until you feel a slight
ridge or bump (always feel the landmark).

 Slide your fingers laterally towards the patient’s right side to find
the second rib. Locate the second intercostal space just inferior to
the rib.

 Move your finger down two more intercostal spaces. It is important

to use firm palpation to correctly locate the fourth intercostal
space. Immediately lateral to the sternum, within the fourth
intercostal space, is the placement of the V1 electrode.

 Continue to locate the other precordial lead positions, using V1 as

the reference point

 When placing electrodes on female patients, always place chest

lead V4 under the breast.
Move V4 to the right of the sternum, 5th intercostal space mid-clavicular
line, to become V4R.

V4R is used to get a more accurate view of the Right Ventricle, and may be
useful in cases of suspected RV Infarct.

Right Ventricular Infarction is a common occurrence in cases of Inferior

STEMI (40% incidence) and should routinely be investigated in the
presence of any Inferior STEMI pattern.

In particular, suspected RV Infarction is indicated on standard placement

12 Leads by the presence of

 ST depression in Lead I

 ST elevation in V1

 ST elevation in V1 > ST elevation in V2.

 Isoelectric or elevated ST segment in V1 and marked ST segment

depression in V2 (highly specific to RV Infarct)

If RV Infarct is suspected, consider performing an additional 12 Lead with

V4R. Always manually relabel V4R

ST elevation in V4R >1mm (for RV Infarct)

-sensitivity of 88%

-specificity of 78%

Key Treatment Points

 Patients with RV infarction are very preload sensitive (due to poor

RV contractility) and can develop severe hypotension in response to
nitroglycerin.

 Hypotension in right ventricular infarction is treated with fluid

loading, and nitrates are contraindicated.
Replace V4/5/6 with "V7/8/9"

V7 – Left posterior axillary line, in the same horizontal plane as V6.

V8 – Tip of the left scapula, in the same horizontal plane as V6.

V9 – Left paraspinal region, in the same horizontal plane as V6.

Suspect Posterior MI with marked Precordial ST Depression V1-4

>1mm (sensitive)

ST Elevation in V7/8/9 >0.5mm adds specificity

The Lewis Lead ECG is used in order to have a specific and detailed view
of atrial activity. This may be clinically useful when atrial flutter is
suspected but not clearly demonstrated.

To create the Lewis Lead, move the Right Arm electrode to the 2nd
intercostal space, right of the sternum, and move the Left Arm electrode
to the 4th intercostal space, right of the sternum (traditionally the
landmark for V1). Leave the lower limb leads in standard place.

Finally, to read the Lewis Lead, print your rhythm strip in Lead I.