Proposed Bedside Maneuver to Facilitate Accurate Anatomic Orientation for Correct Positioning of ECG Precordial Leads V1 and V2: A Pilot Study.
ABSTRACT Misplacement of right precordial electrocardiogram (ECG) electrodes superiorly is a prevalent procedural error that may lead to false findings of T-wave inversion or QS complexes in V2-possibly triggering wasteful utilization of health care resources. Standard technique for proper placement of V1-V2 entails initial palpation for the sternal angle, pointing to the second intercostal space (ICS), followed by lead fixation at the fourth ICS.
Because adherence to this approach may be limited by lack of a visual landmark for the second ICS, we assessed an alternative technique.
The evaluated technique involved placement of the patient's hand up against the base of his/her neck (H→N maneuver) to help demarcate visually a specific point "X" on the chest.
Of 112 patients studied, "X" landed on the first rib in 2.7%, first ICS in 7.1%, second rib in 56.3%, second ICS in 33.0%, and third rib in 0.9%. Thus, in 89.3% (95% confidence interval 83.6-95.0%) of cases (93.3% of men, 84.6% of women; p=0.13), the second ICS could be identified by H→N via the following simple rule: Utilize "X" if it overlies an ICS; or the immediately subjacent ICS if "X" overlies a rib.
The H→N maneuver provides a primarily visual approach to identifying the second ICS and, thereby, the fourth ICS for affixing V1-V2. If the present initial experience is confirmed, H→N might merit consideration as an educational tool to promote anatomically correct placement of these precordial leads, a prerequisite to diminishing the incidence of ECG procedure-related "septal ischemia/infarction."
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ABSTRACT: This study was conducted to assess the impact (diagnostic, therapeutic, and disposition) of the 12-lead electrocardiogram (ECG) on emergency department (ED) patient evaluation and management. This project was a prospective study of a convenience sample of 304 ED patients undergoing ECG analysis during their evaluation in the ED of a level 1 trauma center. The data collection for this study was divided into 4 parts. In part I, the treating physicians determined the specific reasons for ECG analysis; categories include complaint-based (eg, chest pain), syndrome-based (eg, overdose/poisoning), and system-based (eg, "requested by consult"). In part II, all treating physicians were surveyed before ECG interpretation regarding the future diagnostic, therapeutic, and disposition plans for the patient based only on history and physical examination. Their comments were recorded on a standardized data sheet. In part III, the physicians were surveyed after their interpretation of the ECG as to whether the results could suggest any further diagnostic information (eg, normal vs abnormal), or provide enough information for the patient care plan to be altered. In part IV of the study period, alterations to the original diagnostic, therapeutic, and disposition plans made by information provided by the ECG were obtained from the treating physician. A total of 304 patients underwent ECG examination and were used for data analysis. The average age of patients, of which 48% were men, was 60 years. The most common complaints that prompted electrocardiographic evaluation were chest pain and dyspnea. The most common reason an ECG was ordered was nursing staff protocol. Physicians determined that they were able to make a diagnosis based primarily on ECG in 33 (10.9%) cases. The total number of ECGs that were determined to be normal was 95 (31.3%), 7 (2.3%) of which allowed a rule-out diagnosis; 209 (68.7%) of total ECGs were determined to be abnormal, 72 (23.6%) of which were considered "of diagnostic significance." In 96 (31.6%) cases of electrocardiographic interpretation, alterations were made to the diagnostic, therapeutic, or disposition plans because of the information provided by the ECG. The ECG provides clinical information that frequently alters the management plan.The American journal of emergency medicine 11/2007; 25(8):942-8. DOI:10.1016/j.ajem.2007.02.038 · 1.15 Impact Factor
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ABSTRACT: Variability in precordial lead placement is a recognized source of electrocardiographic inaccuracy and lack of reproducibility. In an attempt to reduce error, we evaluated a new device to facilitate and guide precordial lead placement. This study involved three phases: (1) comparison of device-guided electrocardiogram with ECGs obtained by deliberate misplacement of precordial leads on the same patient; (2) electrocardiograms obtained by using the precordial lead device versus those obtained by standard technician methods; (3) reproducibility of precordial electrocardiographic leads between two technicians using the device to guide lead placement. Deliberate misplacement of precordial leads by 2 cm resulted in significant electrocardiographic interpretation changes in all patients. Comparing electrocardiograms obtained after device-guided precordial placement with those obtained after technician placement resulted in variations in 60% of patients including changes in R-wave amplitude, ST segments, Q waves, and transition zone. Significant Q-wave appearance/disappearance and/or significant ST-segment elevation/depression occurred in 19% of patients in Phase II. Sixteen percent of electrocardiograms showed significant changes when analyzed by an experienced electrocardiographer and 10% when interpreted by computer. Variable lead placements and resulting electrocardiographic alterations were not seen by either of two technicians when the device was used. This study confirms the widespread variability in precordial electrocardiograms secondary to lead misplacement. The use of a device to assist in the placement of precordial leads ensures accuracy and reproducibility of electrocardiography. Improved precision and quality control in this laboratory test have important implications in health care and its costs.Clinical Cardiology 07/1991; 14(6):469-76. · 2.23 Impact Factor
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ABSTRACT: Placement of precordial electrodes by 30 experienced technicians during routine electrocardiography was compared with anatomically ascertained sites marked by ink visible only under ultraviolet "black light" in three men and five women. The distance and direction from each marked site to the center of the applied electrode was measured to allow calculation of both the linear magnitude of difference (derived from the square root of the sum of the squares of rise and run) and also the direction of difference (in quadrants) between the anatomically established location and the electrode at each precordial site. The average difference from the applied electrodes to the corresponding marked sites was 1.14 inches, ranging from a mean of 1.31 inches at lead V1 to 0.98 inches at lead V4. Overall, 64% of precordial electrodes were placed within a radius of 1.25 inch, ranging from 56% for lead V6 to 74% for lead V4, and 27% of precordial electrodes were placed within a radius of 0.625 inch. There was superior quadrant displacement of more than 0.625 inch in more than 50% of routine applications of leads V1 and V2, indicating that these electrodes are commonly placed both high and wide of their anatomically defined precordial sites. Similarly, there was an inferior and left-ward displacement of more than 0.625 inch in 30-50% leads of routine applications of V4 through V6, indicating that these lateral precordial electrodes are commonly placed both low and wide of their respective anatomic sites.Journal of Electrocardiology 08/1996; 29(3):179-84. DOI:10.1016/S0022-0736(96)80080-X · 1.36 Impact Factor