• Screening for congenital or acquired heart disease.
• Follow-up of established cardiac disorders:
• Evaluation of apparent life-threatening event, syncope, chest
pain, or new-onset seizure.
• Arrhythmia detection and evaluation.
• Evaluation of conduction disorder.
• Monitoring cardiac effects of medication.
• Evaluation for appropriate pacemaker or defibrillator function.
• Evaluation of cardiac effects of electrolyte or metabolic abnormalities.
• Disorders that limit access to skin of chest
wall, such as thoracic wound.
• Extensive bandages over chest.
• Third-degree skin burns.
• Improper lead positioning is a major source of
• The most common recording error is limb lead reversal.
• Automated ECG interpretations that read “left atrial rhythm” usually
reflect limb lead reversal.
• Negative P, QRS, and T waves in leads I and aVL are another indicator
of lead reversal.
• Make sure the initial recording is at the appropriate speed: 25
mm per second, and appropriate gain: 10 mm per mV.
• Eliminating as much patient movement as possible is essential;
blowing bubbles over young children often allows time for recording
• Clean the area with alcohol swab.
• Skin must be clean and dry.
• Leads cannot be placed over bandages: either reposition bandage
or omit lead.
• Supine position is essential.
• Some patients have T wave changes in upright positions, and decubitus
positioning may slightly alter the location of the heart relative
to the ECG leads.
• Lead placement is important and must be consistent.
• Inappropriate placement of limb or precordial leads results in
interpretation errors, including hypertrophy or infarct patterns.
• Figure 23–1 shows placement of
• RA: Right forearm, distal to insertion
of deltoid muscle.
• LA: Left forearm, distal to insertion of deltoid muscle.
• RL: Right leg.
• LL: Left leg.
• V1: Fourth intercostal space, right sternal edge.
• V2: Fourth intercostal space, left sternal edge.
• V3: Halfway between V2 and V4.
• V4: Fifth intercostal space, midclavicular line.
• V5: Same level as V4 on anterior axillary line.
• V6: Same level as V4 on midaxillary line.
• Place electrode stickers appropriately.
• Attach the leads, with careful attention to limb lead placement.
• Enter the patient data into the ECG machine. ECGs without ...
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