Settling an Argument: Prehospital Limb Lead Placement

Early commercial ECG machine and electrodesIn the prehospital setting, when you’re obligated to be both treating (mostly) fully-clothed patients and moving them through various public spaces, the logistics of the ECG are slightly more complicated than in the hospital setting.

Although the anatomical landmarks of the precordial leads are known and usually utilized by prehospital providers, there is significantly greater variation in the placement of the limb leads; whether driven by circumstance or preference, the limb leads (RA, RL, LA, LL) may be placed in a number of places ranging from the anterior chest wall and abdomen to distal wrists and ankles. BLS providers seeking to help their paramedic partner frequently ask their preference; however, there is a clinically correct answer.

The Question: Where should the limb leads be placed for a standard 12-lead?

The Short Answer: Limb leads should be placed on the limbs, distal to the shoulders and hips but not necessarily on the wrists and ankles.

The Long Answer: A 2007 article in Circulation outlines the AHA’s recommendations for standardization of the ECGs. The authors reference a 1975 statement released by the AHA that recommends limb lead placement “on the arms and legs distal to the shoulders and hips, and thus not necessarily on the wrists and ankles” as the leads had been placed traditionally. **Note– despite my best efforts, including a thorough search of the Circulation archives, I cannot find this original reference; the closest thing I can find is a 1967 recommendation on the standardization of ECGs, in there is no discussion of lead placement.**

The authors continue to explain that one study found variations in limb lead placement (on a given limb) can alter the ECG, specifically the amplitude and duration. They go on to explain that, because there isn’t great evidence surrounding the question, we don’t know if the differences are significant enough to alter diagnostic criteria.

Then there is the more important question of limb lead placement on the torso, which is also called the Mason-Likar lead position. (Lead positioning in this system has the arm electrodes placed in the infraclavicular fossae medial to the deltoid insertions with the left leg electrode placed midway between the costal margin and iliac crest in the left anterior axillary).

While the AHA acknowledges that rhythm diagnosis is not adversely affected by lead placement on the torso, tracings that use this position differ significantly from the standard 12-lead ECG. Specifically, “electrodes placed on the trunk do not provide standard limb leads, and distortion of the central terminal alters the augmented limb leads and the precordial leads.” Differences in QRS morphology and repolarization may then lead to false-negative and/or false-positive infarction criteria.

So despite the fact that placement on the torso may reduce artifact, “ECGs recorded with torso placement of the extremity electrodes cannot be considered equivalent to standard ECGs for all purposes and should not be used interchangeably with standard ECGs for serial comparison.

The Takeaway: If, as a prehospital provider, you place your electrodes on the patient’s limbs distal to the shoulders and hips, your prehospital tracings can be considered a part of the serial-ECG monitoring of patients with ACS. The same is not true with torso limb lead placement.

BONUS QUESTION: Should precordial electrodes be placed above or underneath the breast of a large-breasted woman?

AHA Answer: Despite one study that said that “reproducibility of ECG measurements is slightly increased when electrodes are positioned on top of the breast,” the under-breast placement leads to more intuitive lead placement and would reduce amplitude attenuation caused by torso impedance. So, until further studies say otherwise, under-boob placement it is.

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The importance of pre-hospital ECGs

The last issue of Prehospital Emergency Care (PEC) published a couple of articles about prehospital ECGs, including this one: A Prospective Evaluation of the Utility of the Prehospital 12-lead Electrocardiogram to Change Patient Management in the Emergency Department.  (If you have access to this journal or article, please let me know–I can’t find any way to access it, even after trying several hospital databases).

This article discusses how prehospital ECGs can capture clinically significant abnormalities that aren’t always found in the first ED ECG, and that these prehospital ECGs influence the physician’s treatment plan roughly 20% of the time.

Two questions came to mind after reading that abstract.  First, how good are paramedics at interpreting ECGs (specifically those that change the clinical course of a patient), and second, what about lead placement?

The first question is less pertinent to the article, but if the prehospital ECG is the deciding factor in a patient’s clinical course, paramedic providers should also recognize this sign.  A quick PubMed search, however, suggests that this might not always be the case.  An article from PEC last year concluded that, despite extensive training and a high level of confidence, ED physicians cannot rely solely on paramedic providers to activate the cath lab.  That stings a little bit.  But that’s a conversation for another time.

More concerning is if prehospital ECGs are truly capturing the “clinically significant” ECG abnormalities that influence physicians’ treatments.  One 2012 study looked at how the displacement of electrodes by one intercostal space can affect the ECG interpretation about 20% of the time. Another found that precordial lead displacement significantly affects ECG morphology; however, it did not extrapolate to clinical significance.  (This study also commented on the classic over-breast/under-breast dilemma faced with precordial lead placement! Skip to the discussion to see what they say).

Not only does lead placement affect the accuracy of the ECG, but lead displacement is common even in the hospital setting and when done by clinical ‘experts’ identifying correct sites for placement.

Perhaps then, we should put a little more consideration into our ECG skills and lead placement.  It’s easy slap some leads on in roughly the right places, but that really isn’t good enough.  So here’s some FOAM incase you (or your partner[s]) need a refresher on correct lead placement!

EMS 12-Lead’s Lead Placement Diagrams

LitFL’s Lead Positioning 

CPR Score Sheets

Clinical Scoring_Fotor

I’m working on a CPR improvement program for my agency.  The goal, more than anything else, is simply to practice skills we don’t perform very often.  More specifically though, we want to work on both the clinical aspects as well as the leadership and management aspects of running a resuscitation (you might be noticing a theme with some of my interests).

So another medic and I (you know who you are) have been working on the logistics of it.  It took a little bit of time and consideration, but using the High-Performance CPR Toolkit and a number of CPR leadership studies, we developed these score sheets to quantify, evaluate, and track the quality of simulations in our company.

Leadership Scoring_Fotor

My question to you is, do you have something similar at your company or training institution?  What do you think of the scales on the clinical sheet?  I feel as though those are hard to develop until you actually see a scenario or two.  Any feedback would be greatly appreciated.

*I found the tense discrepancies in the leadership scoring sheet and fixed it on the original

**the clinical evaluation includes QCPR data that allows us to look at compression depth, rate, etc.