Abstract
Background
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.
Study Objective
Because adherence to this approach may be limited by lack of a visual landmark for
the second ICS, we assessed an alternative technique.
Methods
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.
Results
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.
Conclusion
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.”
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of Emergency MedicineAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Recommendations for the standardization and interpretation of the electrocardiogram: part I: the electrocardiogram and its technology: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology.Circulation. 2007; 115: 1306-1324
- Impact of the 12-lead electrocardiogram on ED evaluation and management.Am J Emerg Med. 2007; 25: 942-948
- Standardization of precordial leads: joint recommendations of the American Heart Association and the Cardiac Society of Great Britain and Ireland.Am Heart J. 1938; 15: 107-108
- Standardization of precordial leads: supplementary report.Am Heart J. 1938; 15: 235-239
- Variability of electrocardiographic precordial lead placement: a method to improve accuracy and reliability.Clin Cardiol. 1991; 14: 469-476
- Variability of precordial electrode placement during routine electrocardiography.J Electrocardiol. 1996; 29: 179-184
- The ECG bridge to the twenty-first century: progress report for 1997 and future directions (presidential talk at Palm Coast 1997).J Electrocardiol. 1998; 30: 196-197
- The resting electrocardiogram.in: Fuster V. Alexander R.W. O’Rourke R.A. Hurst’s the heart. 10th edn. McGraw-Hill, New York2001: 281-314
- Serial ECG recordings via marked chest wall landmarks: an essential requirement for the diagnosis of myocardial infarction in the presence of left bundle branch block.J Electrocardiol. 2002; 35: 299-302
- On the appropriate recording of the electrocardiogram.J Electrocardiol. 2007; 40: 65-66
- The relative accuracies of ECG precordial lead waveforms derived from EASI leads and those acquired from paramedic applied standard leads.J Electrocardiol. 2003; 36: 179-185
- Accuracy of ECG electrode placement by emergency department clinicians.Emerg Med Australas. 2007; 19: 442-448
- Electrocardiographic poor R wave progression: III the normal variant.J Electrocardiol. 1980; 13: 135-142
- A method for the accurate placement of chest electrodes in the taking of serial electrocardiographic tracings.Can Med Assoc J. 1960; 82: 258-261
- Electrode misplacement and artifact.in: Chan T.C. Brady W.J. Harrigan R.A. ECG in emergency medicine and acute care. Elsevier Mosby, Philadelphia, PA2005: 16-21
- No test is too routine to do properly.Int J Clin Pract. 2008; 62: 8-9
- Pseudoinfarction pattern by misplacement of electrocardiographic precordial leads.Am J Emerg Med. 2004; 22: 62-63
- Chou’s electrocardiography in clinical practice.5th edn. W.B. Saunders, Philadelphia, PA2001
- QS- and QR-pattern in leads V3 and V4 in absence of myocardial infarction: electrocardiographic and vectrocardiographic study.Circulation. 1955; 12: 391-405
- Clinical significance of QS complexes in V1 and V2 without other electrocardiographic abnormality.Ann Noninvasive Electrocardiol. 2004; 9: 39-47
- Electrocardiography.in: Topol E.J. Textbook of cardiovascular medicine. 3rd edn. Lippincott Williams & Wilkins, Philadelphia, PA2006: 977-1011
- Importance of recognizing pseudo-septal infarction due to electrocardiographic lead misplacement.Am J Med. 2012; 125: 23-27
- Brugada syndrome: diagnositic pitfalls.J Emerg Med. 2009; 37: 79-81
- Poor R-wave progression.J Insur Med. 2005; 37: 58-62
- Chou’s electrocardiography in clinical practice.5th edn. W.B. Saunders, Philadelphia, PA2001
- Macfarlane P.W. Lawrie T.D.K. Comprehensive electrocardiology: theory and practice in health and disease. Volume 3. Pergamon Press, New York1989
- Correlation of electrocardiographic and pathologic findings in anteroseptal infarction.Am Heart J. 1948; 36: 535-575
- The quest for optimal electrocardiography. Task Force I: standardization of terminology and interpretation.Am J Cardiol. 1978; 41: 130-145
- ECG-SAP (Electrocardiography Self-Assessment Program): examination book.American College of Cardiology, Bethesda, MD1995
- Macfarlane P.W. Lawrie T.D.K. Comprehensive electrocardiology: theory and practice in health and disease. Volume 3. Pergamon Press, New York1989
- Marquette™ 12SL™ ECG analysis program: physician’s guide, revision E.GE Medical Systems, Milwaukee, WI2008
- Location of myocardial infarcts: a confusion of terms and definitions.Am J Cardiol. 1978; 42: 868-872
- Does the electrocardiographic pattern of “anteroseptal” myocardial infarction correlate with the anatomic location of myocardial injury?.Am J Cardiol. 1995; 75: 763-766
- Correlation between electrocardiographic subtypes of anterior myocardial infarction and regional abnormalities of wall motion.Coron Artery Dis. 2000; 11: 489-493
- Concordance of electrocardiographic patterns and healed myocardial infarction location detected by cardiovascular magnetic resonance.Am J Cardiol. 2006; 97: 443-451
- Comparison of P-wave patterns derived from correct and incorrect placement of V1-V2 electrodes.J Cardiovasc Nurs. 2009; 24: 156-161
- Electrocardiography: practical applications with vectorial principles.3rd edn. Appleton-Century-Crofts, Norwalk, CT1985
- Principles of clinical electrocardiography.12th edn. Lange Medical Publications, Los Altos, CA1986
- Lipman-Massie clinical electrocardiography.8th edn. Year Book Medical Publishers, Inc, Chicago, IL1989
- Marriott’s practical electrocardiography.10th edn. Lippincott Williams & Wilkins, Philadelphia, PA2001
- Electrocardiography for nurses: physiological correlates.John Wiley & Sons, New York, NY1981
- Clinical electrocardiography for nurses.2nd edn. Aspen Publishers, Rockville, MD1989
- Introduction to electrocardiography.in: Kinney M.R. Packa D.R. Comprehensive cardiac care. 8th edn. Mosby, St. Louis, MO1996: 58-85
- Electrocardiography.in: Woods S.L. Froelicher E.S. Motzer S.A.U. Cardiac nursing. 5th edn. Lippincott Williams & Wilkins, Philadelphia, PA2005: 326-360
- Understanding 12-lead EKGs: a practical approach.2nd edn. Pearson Prentice Hall, Upper Saddle River, NJ2006
- Clinical electrocardiography: a simplified approach.7th edn. Elsevier Mosby, Philadelphia, PA2006
- A standardized procedure for locating and documenting ECG chest electrode positions.J Electrocardiol. 1998; 31: 17-29
- Standard 12-lead electrocardiogram: principles and techniques.in: Chan T.C. Brady W.J. Harrigan R.A. ECG in emergency medicine and acute care. Elsevier Mosby, Philadelphia, PA2005: 3-6
- What the Journal of Electrocardiology can do for electrocardiogram technologists: an electrocardiogram technologist’s perspective.J Electrocardiol. 2006; 39: 3-6
- Accuracy in ECG lead placement among technicians, nurses, general physicians and cardiologists.Int J Clin Pract. 2008; 62: 65-70
- A simple procedure for positioning precordial ECG and VCG electrodes using an electrode locator.J Electrocardiol. 1976; 9: 35-40
- The evaluation of a precordial ECG belt: technologist satisfaction and accuracy of recording.J Electrocardiol. 2001; 34: 155-159
- Accuracy of the precordial V-quick patch in persons with cardiac or pulmonary disease.J Emerg Med. 2003; 24: 131-139
- Electrocardiographic recording and timeliness of clinician evaluation in the emergency department in patients presenting with chest pain.Am J Cardiol. 2007; 99: 1115-1118
- Electrocardiographic ST-segment elevation: correct identification of acute myocardial infarction (AMI) and non-AMI syndromes by emergency physicians.Acad Emerg Med. 2001; 8: 349-360
- Implications of the failure to identify high-risk electrocardiogram findings for the quality of care of patients with acute myocardial infarction: results of the emergency department quality in myocardial infarction (EDQMI) study.Circulation. 2006; 114: 1565-1571
- Electrocardiogram differentiation of benign early repolarization versus acute myocardial infarction by emergency physicians and cardiologists.Acad Emerg Med. 2006; 13: 961-966
- Differences between local hospital and core laboratory interpretation of the admission electrocardiogram in patients with acute coronary syndromes and their relation to outcome.Am J Cardiol. 2007; 100: 169-174
- Comparison of self-reported and measured BMI as correlates of disease markers in U.S. adults.Obesity. 2007; 15: 188-196
Article info
Publication history
Published online: April 16, 2012
Accepted:
January 18,
2012
Received in revised form:
July 3,
2011
Received:
February 18,
2011
Identification
Copyright
© 2012 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
