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  • • Screening for congenital or acquired heart disease.

    • Follow-up of established cardiac disorders:

    • • Progression of chamber enlargement.

      • Hypertrophy.

      • Conduction disorders.

      • Ischemic changes.

    • 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.

  • • ECG machine, leads.

    • Electrode stickers; pediatric patches are best.

    • Alcohol pads to clean skin.

  • • Improper electrical grounding may deliver electrical shock; extremely rare.

  • • Improper lead positioning is a major source of abnormal tracings.

    • • Results in repeat ECGs or unnecessary further testing.

      • As many as 15–20% of pediatric ECGs performed in emergency departments or intensive care units show improper lead placement.

    • The most common recording error is limb lead reversal.

    • White electrode should be on right arm.

      Black electrode should be on left arm.

    • 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 without movement.

  • • 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 leads.

    • • 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 name, age, and ...

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