CONDUCTING THE 12 LEAD ECG

As a Regulated Health Professional responsibilities include not only performing an

accurate diagnostic test but to also ensure the safety, privacy, and rights of the client or
patient. The following communication scenarios, patient care suggestions, and technical
tips, will assist you in meeting the Regulated Health Professional College requirements
related to ECG assessments.
PRIOR TO BEGINNING A TEST
1. Check the patients chart for the requisition or order and other related information.
2. Wash / gel hands prior to beginning the test. The attached tutorial is very
informative.
http://www.publichealthontario.ca/en/BrowseByTopic/InfectiousDiseases/Pages/Han
d_Hygiene.aspx)
3. Verify the patients ID by checking his/her wristband or asking them to state their
first and last name. Introduce yourself including your professional title.
4. Ask if patient has had an ECG before. The procedure should be explained to the
patient according to their past experiences. (Introducing oneself and outlining the
procedure helps alleviate patient apprehension, increases comfort, and ultimately,
leads to a better quality test.)
5. Ask the patient if they are allergic to anything. Our concern is allergies to adhesives.
6. The risks and benefits are described to the patient.
7. The patient is asked if they have any questions.
8. Ask if you can proceed, when the questions have been answered. This process is
called informed consent.

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PREPARING THE PATIENT

1. Ask patients to remove upper body clothing and use a patient gown, if not already in
one. Provide a private area for patient to undress and maintain privacy. Explain to
the patient you will need to expose their chest. Request any visitors leave the room
unless otherwise indicated by the patient.
2. Do not ask the patient to remove any jewelry; just move the jewelry out of the area
involved, as it may interfere with the tracing. No jewelry should be between the
electrode and the heart or touching electrodes. NOTE: Watches may need to be
removed if you notice interference in your printout.
3. Proper skin preparation is essential to producing a high quality tracing. Electrode
sites should be cleaned with alcohol and allowed to dry or rubbed with dry gauze.
4. Place patient in supine or if they are unable to lie flat, a semi-supine position for the
ECG collection.
5. Adhesive sticker electrodes hold each lead in place. For correct electrode and
cable placement please refer to the following table:
TABLE 1: ECG ELECTRODE PLACEMENT
Colour/Label
Placement
White/RA

Right Arm

Black/LA

Left Arm

Green/RL

Right Leg

Red/LL

Left Leg

Red/V1

4th intercostal space on the right side of the sternum

Yellow/V2

4th intercostal space on the left side of the sternum

Green/V3

Midway between V2 and V4

Blue/V4

5th intercostal space, midclavicular line

Orange/V5

Intercostal space in anterior axillary line; midway between

V4 and V6

Purple/V6

5th intercostal space, midaxillary line (curves up)

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5. Alternate limb lead placement may be on the torso instead of the wrists and ankles.
(Mason-Likar). This would be appropriate if the limbs are moving a lot. (Consider
amputations, IVs, wounds, casts, burns), however it is not best for diagnosis, as the
amplitude of waves may be altered. M-L must be recorded on the report if used.
6. Electrodes should not touch one another. On an infants chest leads this may be a
problem. You may cut the electrodes in half to fit on the chest and keep costs down.
7. Other patient skin conduction problems are the diaphoretic patient, or the patient
who is very hairy. Solutions are as varied as the problems but ideally you should
correct the problem (i.e. shave a hairy chest, dry a diaphoretic chest).
8. Alligator clips are attached to the electrodes or stickers, and alligator clips are
firmly attached to the cables which go to the ECG recording machine.
9. Patients may be apprehensive. Some may feel that we could electrocute them.
Explain that we are just recording the activity of their heart. Ask them to lie still and
think about something pleasant.
10. Encourage the patient to relax fully on the stretcher to reduce muscular tremors and
ask them to breathe regularly and easily. Stress the importance that they not speak
for the duration of the test.
RECORDING THE ECG TRACING
1. Ensure correct lead hook up. Look at the Lead II tracing. All waves should be upright
and all AVR waves should be negative waves. In a normal patient there should be R
wave progression. This means that the R waves get progressively taller as you look
at the tracing from V1 through to V6.
NOTE: If you have checked your leads and they are placed correctly but aVR is still
positive, consider that the patient may have dextrocardia:
DEXTROCARDIA
In dextrocardia, the heart may be situated opposite to the normal placement, so that
the left chambers are on the anatomical right and the right chambers on the left
side, or the heart may be oriented normally, but situated to the right of the sternum.
Once true dextrocardia is recognized, the polarity of the leads should be reversed to
get a standard tracing. See Figure 5.1.
(When running chest leads, V1 and V2 placement is the same, but designation is
reversed. V3V6 placement is in the right chest, not on the left as with a normal
heart.)

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FIGURE 5.1:

STANDARD LEAD TRACINGS:

A. Dextrocardia

B. Normal

2. Consider some special patient circumstances that may lead to artifact in the ECG
tracing. Examples include:
- supine position,
- pain,
- SOB, deep breathing,
- talking, chewing gum,
- shivering, DTs,
- muscle tensing, gripping, nervous ticks, age (children/ infants),
- pacemakers,
- muscular patient, obese patient
- large breasts
3. Look for any remaining equipment related artifact. Examples of common artifact are:
- AC interference,
- loose leads,
- dirty or poor connections,
- cracked wires
- muscular interference

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4. Consider the Sensitivity setting. Is the tracing too tall or too short for the paper?
(This is discussed in the next section)
5. Once all artifacts have been eliminated, ask the patients to lie still in a relaxed state
for 10 seconds and push the record or start button.
6. Evaluate the paper tracing to ensure that it is acceptable.
7. Consider doing the tracing at another paper speed, or doing a rhythm strip.
8. Has the patient ID information been entered into the computer? Add comments. ie
torso or wrists and ankles, different sensitivities or paper speeds.
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9. Inform patient of completed test.

10. Remove alligator clips.
11. Remove stickers if the ECG is being done for diagnostic purposes and there will not
be a need for any further ECGs. If the patient is likely to have repeat ECGs, i.e. in
the ER department or clinical unit for ongoing assessment of chest pain, etc. then
leave the ECG stickers in place to ensure all subsequent ECGs are done with the
same lead placement.
12. Document test completion in patient chart or on requisition.

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ECG PAPER/ SENSITIVITY / SPEED

ECG PAPERS (SINGLE CHANNEL VS 12 LEAD or 15 LEAD)
(Heat sensitive, coated, Z fold)

A single lead strip of ECG tracing can be printed or a sampling of all 12 leads can be
printed together.

A single lead, usually L2 (see Figure 3.1), can be used for some basic interpretations of
arrhythmias but a 12 lead recording (see Figure 3.2) can be more specific in the
diagnosis of arrhythmias and their location.

FIGURE 5.2: A SINGLE RHYTHM STRIP

Now look at the 12 lead normal ECG tracing (Figure 5.3). Observe the layout of leads I,
II, III in the first section, then aVR, aVL, and aVF, followed by V 1, V2, V3, then V4, V5,
and V6. Only a few complexes of each lead are visible.

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FIGURE 5.3: SINUS RHYTHM NORMAL ECG

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STANDARD SENSITIVITY
Sensitivity is a calibration factor that regulates the height of the complexes.
Standard sensitivity of 1 means that 10 mm/mV is equal to 10 mm in height or 10 small
boxes on the vertical axis of the graph paper.
Sensitivity of 2 is 20 mm = 1 mV

This may be used if the complexes are too

small on a Sensitivity of 1.

Sensitivity of is 5 mm = 1mV

This may be used if the complexes are too

large on a Sensitivity of 1.

See Figure 3.3 for samples of S X 1, S X 2, S X

A standardization mark must appear at the beginning or end of each recording. The
height of the standardization mark denotes the sensitivity of , 1 or 2.
The sensitivity should be set to 1 but if it is required to be changed to capture the
complexes adequately, please note the sensitivity change on the ECG.

FIGURE 5.4: STANDARD SENSITIVITY

Standard Sensitivity of 1:

Sensitivity set to 2:

Sensitivity set to :

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PAPER SPEED
Note the paper speed of 25 mm/sec., on Figure 3.4.A faster paper speed spreads out
the complexes which is useful in discerning P waves in some of the very fast rhythms
where the P wave sometimes gets buried in the T wave of the previous complex. Note
the paper speed on the same patient at 25 mm/sec and 50 mm/sec in Figure 5.5.

FIGURE 5.5: PAPER SPEED

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