ECG Lead Placement
Green. Red. Yellow. Black.
Gia has always been fascinated with the ECG. How with only a few clicks, you get to see the electrical activity of the heart and with just a press of the button, you can then print and later on save it for documentation and further reference.
However, there is a problem. Placing all those ECG leads of different colors on the chest of the patient confuses her. This bothers her big time as she thinks to herself, “How will I ever become a good nurse if even something as simple as placing ECG leads can seem so complicated to me? How will I do that in emergencies? I’m afraid I’d mess up.”
Placing ECG Leads like a Boss
Imagine a busy scenario wherein a patient with suspected heart problems is rushed to the ER. Everyone is on panic, the ER is jam-packed with patients for the day. As the patient is complaining of chest pains, the resident on duty orders a 12-lead ECG to done stat. You are the only nurse available since all the other nurses are busy catering other patients. You grab the ECG machine and stare at the different colors in front of you. How will you do it? What is the easiest way to remember to place the leads correctly?
For a 12 lead ECG, there are 10 wires on an ECG machine that are connected to specific parts of the body, specifically, 6 chest leads and 4 limb or peripheral leads. These 6 chest leads are labelled as V leads and are numbered from V1-V6, and are positioned in specific positions on the rib cage.
V1 should be positioned at the 4th Intercostal space to the right of the sternum. V2 is to be placed at the 4th Intercostal space to the left of the sternum and V3 midway between V2 and V4. V4 must be then positioned at the 5th Intercostal space at the midclavicular line, V5 at the anterior axillary line at the same level as V4. And lastly V6 is to be placed at the midaxillary line at the same level as V4 and V5.
Another way to position accurately the leads is to first identify the “angle of Louis”, or “sternal angle”, which can be found when you place your fingers gently at the base of your throat in a central position and move your fingers downward until you can feel the top of the sternum, or rib cage. Then, continue to move your fingers downward until you feel a boney lump, which is the “angle of Louis”.
From then on, move your fingers to the right and you will feel a gap between the ribs. This gap is the 2nd Intercostal space. From this position, run your fingers downward across the next rib, and the next one. The space you are in is the 4th intercostal space. Where this space meets the sternum is the position for V1.
To this again, but this time to the left. Where this space meets the sternum (at the 4th intercostal space) is the position for V2. From this position, slide your fingers downward over the next rib and you are in the 5th intercostal space, look at the chest and identify the left clavicle. The position for V4 is in the 5th intercostal space, in line with the middle of the clavicle (mid-clavicular). V3 sits midway between V2 and V4. Follow the 5th intercostal space to the left until your fingers are immediately below the beginning of the axilla, where you will position V5. Follow this line of the 5th intercostal space a little further until you are immediately below the centre point of the axilla, (mid-axilla). This is the position for V6.
As for the peripheral leads, RL (right leg) lead must be positioned anywhere above the ankle and below the torso. RA (right arm) lead is to be placed anywhere between the shoulder and the elbow, LL (left leg) lead should be positioned anywhere above the ankle and below the torso, and LA (left arm) lead anywhere between the shoulder and the elbow. To help you remember this easily, remember, “READ YOUR GREEN BOOK” starting with your right arm (RED), Left arm (YELLOW), Left Leg (GREEN), Right Leg (BLACK).
It is very important that the ECG leads are placed correctly since incorrect placement can lead to a false diagnosis of infarction or negative changes on the ECG. However, this task should not be a complicated one if one knows the technique to remember it easily. So, now that you know how, go on with confidence and place ECG leads like a boss.