Peter Antevy teaches EMS clinicians where to place electrodes for accurate 12 and 15-lead ECGs. Place limb leads on deltoids and legs to avoid interference, V1-V6 at standard intercostal landmarks, and for 15-lead add V4R on the right chest and posterior leads V8 and V9. Call STEMI alert for 1mm elevation in V4R alone or 0.5 small boxes in both V8 and V9.
Questions this video answers
On the deltoid (outside on the deltoid) to keep leads off the torso.
Below the inguinal ligament (on the legs).
Fourth intercostal space on the patient's right side (parasternal).
Fourth intercostal space on the patient's left side (parasternal).
Fifth intercostal space at the midclavicular line on the patient's left.
Chapters
Today we're going to review EKGs with a focus on STEMI's. This video is designed to be a tutorial for obtaining both a 12 and a 15 lead EKG, calling the STEMI alert, transmitting the EKG to the hospital, and setting the VFVT alarm. However, we're going to simplify this into something easy to remember. See it, say it, send it, set it. In the next few minutes, we're going to focus on these four thoughts to help you provide excellent patient care. The first thing I want you to remember when we are placing a 12 and a 15 lead EKG is we got to make sure we put the limb leads in the correct location. So we're going to start with these limb leads and we're going to put these outside on the deltoid. And the reason we're doing this on the deltoid is because, remember, we're going to have a blood pressure cuff on the arm and we're also going to be attempting to establish vascular access to as soon as possible. So we don't want our 12 lead placement to interfere with all the other treatments we're doing. The important thing to remember with limb leads is they have to be on the limbs outside of the torso. Then we're going to go ahead and put these lower limb leads on the legs. And remember, the important part is that it needs to be below the inguinal ligament. Once we have.
Our limb leads in the proper place and we can confirm that we're definitely getting a clean ekg, what we're going to do is we're going to place our V leads in the proper location. So let's go over this, the placement really quickly. First place is we're going to take v1. Remember, v1 goes in the fourth intercostal space on the patient's right side, and that's going to be parasternal. So V1 is going to go approximately this location in that fourth intercostal space. V2 is going to go in that same fourth intercostal space. However, this is going to go on the patient's left side. Parasternal. The next lead that we want to place is going to be v4. It's important that we also remember that v4 goes in the fifth intercostal space on the midclavicular line. So we're going to place V4 at the midclavicular line in the fifth intercostal space. And, and then what we're going to do is we're going to take V3 and we're going to put this right in the middle of those two. The next one we're going to place is V5. V5 is going to go on the same line as V4. However, this is going to go on the anterior axillary line. The last lead that we're going to place is going to be V6. V6 is going to go on the mid axillary line on the same plane as V.
Once we have our limb leads attached, we're going to go ahead and obtain our first 12 lead EKG. Press the 12 lead button, scroll down to the patient's age or up.
Enter in the patient sex, and the 12 lead's automatically going to run. Remind the patient to stay still for about 30 seconds. Try not to move, try not to tense up so that we get as clean of an EKG tracing as possible. Once it's analyzing, it's going to go ahead and print out that 12 lead EKG.
Now that you've got your 12 lead EKG, make sure you read this and check to make sure that there's no ST segment elevation. Check for any abnormalities as you normally would. But after that, we want to get a 15 lead EKG. We got to put eyes on the posterior wall of the heart. In order for us to look at the posterior wall of the heart, we're going to have to put leads on the patient's back. Tell our patient that we're going to need them to sit forward. We're going to do three things here. We're going to, number one, ask the patient to lean forward. Then we're going to disconnect several different leads.
We're going to disconnect V4. We disconnect V4 and what we're going to do is we're going to take V4 and we're going to place this on the same margin on the right side. So again, this is going to go in the fifth intercostal space, midclavicular on the right. And this is called V4R. So as you can see, we disconnected V4 from the patient's left side. And what we did was we moved V4 over to the right side again. That anatomical location is going to be midclavicular in the fifth intercostal space. This time it's going to be on the patient's right side. We're calling this V4R. Now that we've got V4R, we're going to go ahead and go to the patient's posterior. We're going to disconnect v5 and disconnect v6. At the same time, we're going to move to patient's back.
So we lean the patient forward. And then what we're going to do is we're going to locate our anatomical landmarks. The best thing to do is to locate the patient's scapula and the angle of the scapula where it starts to angle laterally. This is where just beneath that is where you want to go ahead and place V5, which is going to become V8.
Again. The patient's scapula begins to angle laterally at this level. This is where we're going to put V5. Then what we're going to do is we're going to place V6, which is now going to become V9. When we place V6, we want to locate V5 and we also want to locate the spine. These are going to be our primary landmarks and we're going to split the difference and put V6 paraspinal between the mid scapular space, but not on the spine. Now that we've got this in the correct location, we're going to run another 12 lead EKG. Only this time it's going to give us those three views that we're looking for that's going to complete our 15 lead EKG. So if you notice here on the 12 lead EKG, you can see the QRS morphology changes on a standard 12 lead EKG, from being a downright deflection to an upright deflection as it moves laterally around the heart. However, when we put the lead on the right side and the posterior wall, you can see that there's a difference, a definite difference between these two. So what we're going to do is we're going to relabel these so that whenever we turn this over to the hospital, they'll know that this is definitely the 15 and this is definitely, definitely the 12 lead EKG. But we're going to label this as V4R. We're going to scratch out V5 and we're going to write V8, scratch out V6 and we're going to write V9 so that everybody knows this is the 15 lead, this is the 12 lead. Now that we have our 15 lead EKG in our hands, here's the STEMI criteria. If you see 1 millimeter of elevation in V4R alone, call a STEMI alert. If V8 and V9 both show even a half a box of elevation, you can confidently call a stimulert. Remember to let dispatch know and also let the receiving hospital know you are bringing them a STEM alert. This is the say it part per page 53 of the chest Pain protocol. It says that patients experiencing chest pain shall have multiple 12 and 15 lead ECGs performed throughout assessment and transport. The easiest way to do this is is to start by obtaining the 15 lead EKG. Then obtain the 12 lead EKG and leave the patient connected to the monitor in the standard 12 lead configuration. The LifePak 15 is going to continually monitor the ST segment and compare it to the first one that you ran. If it notices a millimeter of change at any point, it's going to automatically print out a 12 lead. If you see the LifePak print out a 12 lead automatically, you you need to pay attention to it. If the LifePak has not printed out a 12 lead EKG automatically and 10 minutes have gone by, go ahead and print out another one, obtain that second 12 lead EKG and compare it to the first serial. 12 lead EKGs are crucial to early identification of a STEMI. If the patient is having an active STEMI, it's important that you transmit that EKG to the hospital immediately.
The last thing I want to remind you of before we go Once you notice that this patient is a positive STEMI alert. When you're sure this patient is having an acute mi, remember to put the pads on the patient. Studies have shown that when you have the pads placed prior to the patient going into VF or VT that it takes less than a minute for the first defibrillation attempt. So remember, put the pads on the patient and also remember to turn on the VFVT Alarm on the LifePak. Thank you so much for your time. We appreciate it. If you have any questions, reach out to the Medical Services Division. Thanks.
