Proposed Bedside Maneuver to Facilitate Accurate Anatomic Orientation for Correct Positioning of ECG Precordial Leads V1 and V2: A Pilot Study

Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan.
Journal of Emergency Medicine (Impact Factor: 0.97). 04/2012; 43(4):584-92. DOI: 10.1016/j.jemermed.2012.01.022
Source: PubMed


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."

7 Reads
  • [Show abstract] [Hide abstract]
    ABSTRACT: Awareness of the problem of false electrocardiographic diagnosis of septal infarction due to cranially misplaced precordial leads V1 and V2, a common technical error, is important because this pseudo-pathologic finding can trigger unnecessary medical procedures and have other adverse sequelae. The non-trivial nature of this problem is emphasized by the case of a patient in whom the misdiagnosis caused loss of an employment opportunity. We demonstrate how P wave morphology in lead V2 can aid the clinician in suspecting erroneous right precordial lead placement in cases of apparent septal infarction. Ultimately, improved education of health care personnel regarding accurate precordial lead positioning technique is needed to minimize the occurrence of this electrocardiographic misdiagnosis.
    The American journal of medicine 08/2011; 125(1):23-7. DOI:10.1016/j.amjmed.2011.04.023 · 5.00 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is considered a progressive cardiomyopathy. However, data on the clinical features of disease progression are limited. The aim of this study was to assess 12-lead surface electrocardiographic (ECG) changes during long-term follow-up, and to compare these findings with echocardiographic data in our large cohort of patients with ARVC/D. Baseline and follow-up ECGs of 111 patients from three tertiary care centers in Switzerland were systematically analyzed with digital calipers by two blinded observers, and correlated with findings from transthoracic echocardiography. The median follow-up was 4 years (IQR 1.9-9.2 years). ECG progression was significant for epsilon waves (baseline 14% vs. follow-up 31%, p = 0.01) and QRS duration (111 ms vs. 114 ms, p = 0.04). Six patients with repolarization abnormalities according to the 2010 Task Force Criteria at baseline did not display these criteria at follow-up, whereas in all patients with epsilon waves at baseline these depolarization abnormalities also remained at follow-up. T wave inversions in inferior leads were common (36% of patients at baseline), and were significantly associated with major repolarization abnormalities (p = 0.02), extensive echocardiographic right ventricular involvement (p = 0.04), T wave inversions in lateral precordial leads (p = 0.05), and definite ARVC/D (p = 0.05). Our data supports the concept that ARVC/D is generally progressive, which can be detected by 12-lead surface ECG. Repolarization abnormalities may disappear during the course of the disease. Furthermore, the presence of T wave inversions in inferior leads is common in ARVC/D.
    BMC Cardiovascular Disorders 01/2015; 15(1):4. DOI:10.1186/1471-2261-15-4 · 1.88 Impact Factor

Similar Publications