12-lead ECG recording

Nicola Stevens. Practice Nurse. Philadelphia: Nov 21, 2008. Vol. 36, Iss. 9; pg. 13, 5 pgs .
Practice Nurse Trainer articles support nurses who train nurses new to general practice, and healthcare assistants. They will focus in 2008 on practical skills relating to the previous issue's New Practice Nurse article

An essential skill for most practice nurses is 12-lead ECG recording. It should be borne in mind that in taking on any new role to enhance patient care you are accountable for your own professional practice and must ensure that you: * use the best available evidence * keep your skills and knowledge up to date * keep clear and accurate records * share information with colleagues.1 Hence, you will need to investigate the training and supervision available locally before agreeing to start carrying out ECG recordings. WHY RECORD AN ECG? Electrocardiography is a non-invasive investigation that records the electrical activity of the heart. The recording of an ECG (an electrocardiogram) is a simple, cost-effective and repeatable assessment tool that should be used in conjunction with other assessments, for example the patient history. These assessments jointly provide the evidence to support a diagnosis. NORMAL CONDUCTION OF THE HEART Electrical activity is conducted through the heart as shown in Figure 1. The sinoatrial (SA) node initiates an impulse that causes depolarisation (contraction) of the heart muscle. This spreads from the node through the atria, allowing contraction of the atria. The SA node also controls the pace of the heart - usually 70-80 beats per minute. Depolarisation continues to the atrioventricular (AV) node, with the electrical discharge passing quickly through the bundle of His - a bundle of specialised fibres within the interventricular septum that divides into right and left branches and then further into the Purkinje fibres -thus allowing contraction of the ventricles. NORMAL 12-LEAD ECG RECORDING A 12-lead ECG records the electrical activity of the heart from 12 different leads or view-points, via 10 electrodes placed on the patient (four on the limbs and six on the chest). An ECG trace (Figure 2) is a series of waves, the size of each wave corresponding to an electrical voltage (measured in millivolts) generated by the heart muscle as it goes through the cycle of contraction and relaxation. Atrial contraction is represented on an ECG by the P-wave (Figure 3). There is a slight delay when the impulse reaches the AV node before it is conducted further to allow ventricular contraction, which is represented by the QRS complex. Relaxation of the heart (ventricular repolarisation) is represented by the T-wave.

The grid on the ECG recording paper (see Figure 2) measures time (in fractions of a second, horizontally) and the size (in millivolts, vertically) of these waves. Horizontally, each small box represents 0.04s and each large box 0.20s. Normally, ECGs are recorded at a speed of 25mm/s and a sensitivity of 10mm/mV. Any variations to this should be clearly identified on the recording to avoid misinterpretation. A multichannel recorder records all 12 leads/viewpoints on a full page layout; a single-channel recorder will record them sequentially. EQUIPMENT A wide range of ECG recorders are available.2 Purchasing decisions need to take account of: * price * reliability * portability * ease of use * servicing * performance characteristics. Hospital-based medical physics departments can help with choosing an appropriate machine that will adhere to the standards of the Medicines and Healthcare products Regulatory Agency.3 PREPARATION FOR RECORDING Familiarise yourself with the local equipment available - a manual should be available to refer to for machine operation. It is also important to know: * how to change the recording paper * how to charge the machine * servicing arrangements * where supplies of electrodes and paper are kept and how to order further supplies. An appropriately trained professional such as a GP, an experienced practice nurse or a trainer should initially offer a practical demonstration. Supervised practice should then be instigated until the skill is mastered competently. PATIENT PREPARATION Explain to the patient why the ECG recording is being made (Box 1) and what the procedure will entail. Emphasise the non-invasive nature of the test and reassure the patient throughout the procedure. The patient should lie flat on the examination couch with a pillow, be comfortable, relaxed and warm (shivering produces muscle tremor, which interferes with the tracing). Privacy should also be ensured. There is usually no need to remove jewellery such as watches unless tracing

problems occur. Tights may be worn as long as there are no contact problems. Bras should be removed to allow correct placement of chest electrodes and a blanket or sheet placed over the patient to provide privacy and warmth. A variety of electrodes are available: chest suction cups and limb plates, which require conduction gel; or selfadhesive electrodes, which require little or no skin preparation. Dry skin flakes or perspiration can be removed with a dry swab. Alcohol-impregnated wipes are not required. Partial shaving is required only in particularly hairy individuals where electrode contact is problematic. ELECTRODE POSITIONING Each lead looks at a specific surface of the heart. The correct positioning of electrodes is therefore essential to obtain a diagnostically useful recording. By attaching electrodes to the right arm, left arm and left leg, just proximal to wrist and ankle, three major planes for detecting electrical activity can be recorded. These three planes form a hypothetical triangle (Einthovens triangle) with the heart in the middle (Figure 4). A fourth electrode is attached to the left leg, but serves only as an earth and is not used for recording purposes. Attach the chest electrodes VI, V2, V3, V4, V5, V6 as shown in Figure 4: * VI - fourth intercostal space to the right of the sternum * V2 - fourth intercostal space to the left of the sternum * Skip to V4 - fifth intercostal space in the mid-clavicular line * V3 - halfway between V2 and V4 * V5 - fifth intercostal space at the anterior axillary line, horizontal with V4 * V6 - fifth intercostal space at the mid-axillary line, horizontal with V4/5. LEAD CONNECTION AND RECORDING Connect the appropriate ECG leads to the electrodes. Encourage the patient not to talk and to be relaxed and still (muscle movement can interfere with the ECG reading). Now record the ECG. This usually takes several seconds. If you are happy with the ECG quality, inform the patient and remove the ECG leads and electrodes. Dispose of the electrodes in a clinical waste bag. Consider offering the patient some wipes to clean their skin. Ask them to dress and make sure they are comfortable. Tell the patient when and how they can expect to receive the results of their ECG. The recording should be labelled with the patient's name, date of birth, community health index (CHI) number and the date and time of the test. Most modern ECG machines will date and time the ECG, but ensure these details are accurate. Also document on the recording any symptoms experienced during the test, such as chest pain. An ECG recording is not validated until it is reviewed by an appropriately trained professional at an appropriate time. Should any abnormalities be suspected or symptoms experienced during the test, the recording should be

reviewed while the patient remains in the surgery. Computer-based interpretation offered on some recorders also needs an appropriately trained professional to validate the result. COMMON TRACING PROBLEMS Three common tracing problems (artefacts or interference) are shown in Figure 5. Often recorders incorporate filters that help reduce artefacts or interference. ABNORMAL TRACINGS It is outside the scope of this article to depict abnormal ECG tracings. However, the further reading section offers some useful resources to supplement further training pertaining to ECG interpretation. CONCLUSION Recording a 12-lead ECG is a diagnostically useful test that is simple to perform and noninvasive to the patient. Professionals recording ECGs need appropriate, up to date evidencebased training, supervision and support.

Indexing (document details)

Subjects: Classification Codes Locations: Author(s): Electrocardiography, Nurse practitioners, Heart, Quality of care, Medical records, Medical diagnosis 9175 Western Europe, 8320 Health care industry United Kingdom--UK Nicola Stevens

Author Affiliation: Nicola Stevens, RON, BN, respiratory research nurse, University of Dundee, Ninewells Hospital, Dundee Stevens N. 12-lead EGG recorobg. Thv.o&e Muse 2008; 36(9): 13-8 Date received: 27 October 2008; raised and updated verSn of odginal artide k~ Pidctice Nuns 2003: 26(2): 18-24. Document features: Publication title: Source type: ISSN: ProQuest document ID: Document URL: Diagrams, Graphs Practice Nurse. Philadelphia: Nov 21, 2008. Vol. 36, Iss. 9; pg. 13, 5 pgs Periodical 09536612 1613170171 http://proquest.umi.com/pqdweb?did=1613170171&sid=4&Fmt=3&clientId=28403& RQT=309&VName=PQD