12-lead electrocardiogram (ECG)

Introduction

Coronary heart disease remains a leading cause of mortality worldwide. Prompt

recognition and treatment of acute coronary syndromes, such as ST-segment elevation
myocardial infarction (STEMI) and non-STEMI acute coronary syndrome, can reduce
and prevent cardiac arrest. 1

Electrocardiography, one of the most valuable and frequently used diagnostic tools,
displays the heart's electrical activity as waveforms. Impulses moving through the
heart's conduction system create electrical currents that can be monitored on the
body's surface. Electrodes attached to a patient's skin can detect these electrical
currents and transmit them to an instrument that produces a record of cardiac activity,
known as an electrocardiogram (ECG). An ECG can be used to identify myocardial
ischemia and infarction, rhythm and conduction disturbances, chamber enlargement,
electrolyte imbalances, and drug toxicity. 23

A standard 12-lead ECG uses a series of electrodes placed on the extremities and the
chest wall to assess a patient's heart from 12 different views (leads). 4 The 12 leads
consist of three standard bipolar limb leads (designated I, II, III), three unipolar
augmented limb leads (aVR, aVL, aVF), and six unipolar precordial leads (V1 to V6). The
limb leads and augmented leads show the heart from the frontal plane. The precordial
leads show the heart from the horizontal plane. (See Understanding ECG leads.)

NDERSTANDING ECG LEADS

Each of the leads on a 12-lead ECG views the heart from a different angle. These
illustrations show the direction of electrical activity (depolarization) monitored by each
lead and the 12 views of the heart.
Views reflected on a 12- Lead View of the
lead ECG heart

Standard limb leads (bipolar)

I Lateral wall
II Inferior wall
III Inferior wall
Augmented limb leads
(unipolar)
aVR No specific view
aVL Lateral wall
aVF Inferior wall
Precordial or chest leads
(unipolar)
V1 Septal wall
V2 Septal wall
V3 Anterior wall
V4 Anterior wall
V5 Lateral wall
V6 Lateral wall
The ECG machine measures and averages the differences among the electrical potential
of the electrode sites for each lead and graphs them over time. This process creates the
standard ECG complex, made up of P-QRS-T. The P wave represents atrial
depolarization; the QRS complex, ventricular depolarization; and the T wave, ventricular
repolarization. (See Reviewing ECG waveforms and components.)

REVIEWING ECG WAVEFORMS AND COMPONENTS

An ECG waveform has three basic components: the P wave, QRS complex, and T wave.
These elements can be further divided into the PR interval, J point, ST segment, U
wave, and QT interval.

P wave and PR interval

The P wave represents atrial depolarization. The PR interval represents the time it takes
an impulse to travel from the atria through the atrioventricular nodes and the bundle of
His. The PR interval is measured from the beginning of the P wave to the beginning of
the QRS complex.

QRS complex

The QRS complex represents ventricular depolarization (the time it takes for the
impulse to travel through the bundle branches to the Purkinje fibers).

The Q wave, when present, appears as the first negative deflection in the QRS
complex; the R wave appears as the first positive deflection. The S wave appears as the
second negative deflection or the first negative deflection after the R wave.
J point and ST segment

Marking the end of the QRS complex, the J point also indicates the beginning of the ST
segment. The ST segment represents part of ventricular repolarization.

T wave and U wave

The T wave usually follows the same deflection pattern as the O wave and represents
ventricular repolarization. The U wave follows the T wave but isn't always seen; it is
seen most frequently during bradycardia in leads V2 and V3. 5

QT interval

The QT interval represents ventricular depolarization and repolarization. It extends from

the beginning of the QRS complex to the end of the T wave.

Variations of the standard ECG include an exercise ECG (stress ECG) and an ambulatory
ECG (Holter monitoring). An exercise ECG monitors heart rate, blood pressure, and ECG
waveforms as the patient walks on a treadmill or pedals a stationary bicycle. For an
ambulatory ECG, the patient wears a portable Holter monitor to record heart activity
continuously over 24 hours.

The ECG is accomplished using a multichannel method. All of the electrodes are
attached to the patient and the machine prints a simultaneous view of all leads.

Equipment
• ECG machine with recording paper
• Disposable pregelled electrodes
• Soap and water
• Washcloths
• Bath blanket or sheet
• Facility-approved disinfectant
• Optional: disposable head hair clippers, single-patient-use scissors, indelible
marking pen, gloves, alcohol pad, 4" × 4" (10-cm × 10-cm) gauze pads
 Preparation of Equipment

Inspect all equipment and supplies. If a product is expired, is defective, or has

compromised integrity, remove it from patient use, label it as expired or defective, and
report the expiration or defect as directed by your facility. Place the ECG machine close
to the patient's bed. Check the cable and wires for fraying or breakage, and replace
them or obtain another machine if necessary. Plug the cord into the wall outlet or
ensure that a battery-operated ECG machine is functioning properly. Turn on the
machine, program or perform a self-test according to the manufacturer's instructions,
and input the required patient information. Most ECG machines have automatic
settings; ensure that the paper speed selector is set to the standard 25 mm/sec,
calibration set to 10 mm/mV, and filter settings set to 0.05 to 100 Hz.

If the patient is already connected to a cardiac monitor, move the electrodes to

accommodate the precordial leads and to minimize electrical interference on the ECG
tracing. Keep the patient away from electrical fixtures and power cords. Depending on
the type of pregelled electrodes used, ensure that they are moist or sticky to promote
impulse transmission.

Implementation
• Verify the practitioner's order.
• Gather and prepare the necessary equipment and supplies.
• Perform hand hygiene.
• Put on gloves, as needed, to comply with standard precautions.
• Confirm the patient's identity using at least two patient identifiers.
• Provide privacy.
• Explain the procedure to the patient and family (if appropriate) according to their
individual communication and learning needs to increase their understanding,
allay their fears, and enhance cooperation. Tell them that the test records the
electrical activity of the patient's heart and that it may be repeated at certain
intervals. Emphasize that no electrical current will enter the patient's body. Also
explain that the test typically takes just a few minutes.
• Raise the bed to waist level before providing care to prevent caregiver back
strain.
• Place the patient in the supine position in the center of the bed, with the arms at
the patient's sides. Raise the head of the patient's bed, if the patient desires, to
promote comfort. Ensure that the patient's arms and legs remain relaxed to
minimize muscle trembling, which can cause electrical interference.
 • Expose the patient's chest, arms, and legs and then cover the patient
appropriately with a bath blanket or sheet.
• Select the electrode sites on the patient. Select flat, fleshy areas on which to
place the limb lead electrodes. Avoid muscular and bony areas. If the patient has
an amputated limb, choose a site on the stump.

Clinical alert: If the electrodes are placed incorrectly, the ECG tracing can be
distorted sufficiently to cause a misdiagnosis. This can result in inappropriate treatment.

• If a selected electrode site is excessively hairy, clip the hair using disposable
head hair clippers to promote electrode adherence to the patient's skin.
• Wash the electrode sites using soap and water and a washcloth. Wipe them with
a dry washcloth or gauze pad to roughen the patient's skin, which helps remove
its outer layer to facilitate electrical signal transmission. If necessary, clean oily
skin using an alcohol pad and allow it to dry.
• Mark the electrode sites with an indelible marking pen if serial ECGs are likely.
• Apply disposable pregelled electrodes to the patient's inside forearms and to the
medial aspects of the ankles or calves; limb leads should be an equal distance
from the heart and in about the same place on each limb. Apply the pregelled
electrodes directly to the prepared sites, as recommended by the manufacturer's
instructions. Apply disposable electrodes on the patient's legs, with the lead
connections pointing superiorly to guarantee the best connection to the lead
wire.
• Apply a pregelled electrode at each electrode site on the patient's chest.
(See Applying chest electrodes.) If the patient is female, be sure to apply the
chest electrodes under the breast tissue.

APPLYING CHEST ELECTRODES

To ensure proper placement of chest electrodes, use palpation to locate the correct
intercostal space. Palpate the point at which the sternum attaches to the clavicle (the
suprasternal notch); then palpate down to identify the sternal angle, which is the bony
prominence at which the second rib attaches to the sternum. The space below the
second rib is the second intercostal space. Continue to palpate down the patient's
sternum, counting the ribs and intercostal spaces to find the appropriate location for
the chest electrodes.

To ensure accurate test results, apply chest electrodes as follows:

V1: Fourth intercostal space at the right border of the sternum

V2: Fourth intercostal space at the left border of the sternum

V3: Halfway between V2 and V4

V4: Fifth intercostal space at the left midclavicular line

V5: In the horizontal plane of V4 at the anterior axillary line (or halfway between V4 and
V6, if the anterior axillary line is ambiguous)

V6: In the horizontal plane of V4 at the midaxillary line

• Connect the lead wires to the electrodes. Note that the tip of each lead wire
is lettered and color-coded for easy identification. The white or RA lead wire goes
to the right arm, the green or RL lead wire to the right leg, the red or LL lead
wire to the left leg, the black or LA lead wire to the left arm, and the brown or

V1 to V6 lead wires to the chest electrodes.

• Instruct the patient to relax and breathe normally. Instruct the patient to lie still
and not to talk when you record the ECG to minimize artifact.
• Press the AUTO or START button (as shown below). The ECG machine records all 12
leads automatically, recording three consecutive leads simultaneously. Some
machines have a display screen that allows you to preview waveforms before the

machine records them on recording paper. Observe the tracing quality.

• Repeat ECG recording, as needed.

• When the ECG machine finishes recording the 12-lead ECG, remove the
electrodes and clean the patient's skin. Disconnect the lead wires from the

electrodes and dispose of the electrodes, as indicated.

• Return the bed to the lowest position to prevent falls and maintain patient
safety.
• Remove and discard your gloves, if worn.
• Perform hand hygiene.
• Put on gloves, as needed.
• Clean and disinfect reusable equipment according to the manufacturer's
instructions to prevent the spread of infection.
• Remove and discard your gloves.
• Perform hand hygiene.
• Document the procedure.
 Special Considerations
• During the procedure, instruct the patient to breathe normally. If the patient's
respirations distort the ECG recording, instruct the patient to hold their breath
briefly to reduce baseline wander in the tracing.
• If the patient has a pacemaker, you can perform an ECG with or without a
magnet according to the practitioner's orders. Be sure to note the presence of a
pacemaker and the use of the magnet on both the ECG strip and in the patient's
medical record.
• Record the ECG with the patient in the same position each time because
different positions may cause differences in the tracings. If another position is
required because of the patient's condition, document the position used on the
tracing and in the patient's medical record.

Documentation

Document in the patient's medical record the date and time that the ECG was
performed and any significant responses by the patient. Verify the date, time, patient's
name, and assigned identification number on the ECG itself. Note any appropriate
clinical information, positioning changes, and calibration variations on the ECG tracing,
and place it in the patient's medical record. Document teaching provided to the patient
and family (if applicable), their understanding of that teaching, and any need for follow-
up teaching.

Reference: Lippincott Manual of Nursing Practice.