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12 lead ECG depicting correct lead placement. (A) ECG recording. (B) Correct lead placements on chest and arms.
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Background: Electrocardiography is a very useful diagnostic tool. However, errors in placement of ECG leads can create artifacts, mimic pathologies, and hinder proper ECG interpretation. This is the second of a two-part series discussing how to recognize and avoid these errors.
Methods: 12-lead ECGs were recorded in a single male healthy subject i...
Contexts in source publication
Context 1
... same subject was analyzed as in Part I of this series, by the same technician and with the same ECG machine (General Electric, Mac 5500, United States) set up at 150 Hz, 25.0 mm/s, and 10.0 mm/V (Figure 1). 2 A series of precordial lead mis- placements were conducted in order to recreate these classic patterns. ...
Context 2
... same subject was analyzed as in Part I of this series, by the same technician and with the same ECG machine (General Electric, Mac 5500, United States) set up at 150 Hz, 25.0 mm/s, and 10.0 mm/V (Figure 1). 2 A series of precordial lead mis- placements were conducted in order to recreate these classic ...
Similar publications
Background: Electrocardiography (ECG) is a very useful diagnostic tool. However, errors in placement of ECG leads can create artifacts, mimic pathologies, and hinder proper ECG interpretation. It is important for members of the health care team to be able to recognize the common patterns resulting from lead placement errors.
Methods: 12-lead ECGs...
Citations
... Validity of the 12-lead ECG depends on the correct acquisition technique and particularly on the accurate placement of precordial (chest) electrodes. Small deviations in electrode placement can significantly alter the waveforms recorded, potentially impacting the provider's interpretation of the ECG (Bond et al., 2012;Harrigan et al., 2012;Kania et al., 2014;Rosen et al., 2014;Rudiger et al., 2006). Misplaced electrodes can lead to false-positive interpretations that can generate needless anxiety, inconvenience, exposure to procedural risk, and expense (Abobaker & Rana, 2021;Drew, 2008;Ilg & Lehman, 2012;Rehman & Rehman, 2020;Toosi & Sochanski, 2008;Walsh, 2018). ...
Background and purpose: A valid 12-lead electrocardiogram (ECG) depends on correct acquisition technique, particularly on the accurate location of precordial (chest) electrodes. The emergency medical services (EMS) segment of the care continuum is under-represented in previous clinically oriented studies of electrode placement. This study sought to assess the accuracy of chest electrode placement by EMS and clinical personnel in one geographic area, to identify patterns of misplacement to inform future training and continuing education, and to compare two methods of assessing electrode placement. Methods: This prospective observational study recruited a convenience sample of EMS and clinical personnel. Participants placed simulated electrodes on a CPR-style manikin and completed a questionnaire about their training and experience. A subset also marked electrode locations on a printed diagram of the ribcage. Digitized placement data and questionnaire responses were analysed statistically. Results: Findings from 149 participants showed misplacement patterns consistent with prior studies, with 41.6% rated as “acceptable” and 34.2% placing £ 3 electrodes acceptably. Correctness of electrode placement was comparable between EMS and clinical participants. More correct electrode placement correlated with classroom vs. on-the-job training, frequent vs. infrequent practice, and greater self-confidence. The diagram data collection method proved not equivalent to, and probably less reliable than, the hands-on manikin method for assessing placement skills. Conclusions: Significant variation in ECG chest electrode placement by EMS personnel was comparable to that previously reported for clinical personnel, suggesting that existing concerns about placement errors by clinical personnel may apply equally to EMS personnel. More frequent practice and classroom-based initial ECG training were associated with significantly greater placement accuracy. Participants used diverse strategies to identify electrode locations. Further research is warranted to clarify optimal strategies for placing chest electrodes, especially on diverse body types. Sound initial ECG training and continuing education are necessary to reinforce high-quality ECG skills.
... Наложить электроды, начиная с конечностей. Электроды накладываются в соответствии с таблицами 1 и 2 16,18 [2,3]. 18 2. Смещая пальцы вниз, определить положение угла грудины (место несколько ниже манубриостернального сочленения, у взрослых -консолидированного), непосредственно рядом с которым или несколько ниже его при смещении по горизонтали Зарегистрированные по этим схемам ЭКГ необходимо промаркировать "по Мейсону-Ликару", "по Хану" или "по Лунду", поскольку имеются сведения о неполном соответствии между ЭКГ со стандартным и смещенным положением электродов [8,[12][13][14]. ...
... Электроды накладываются в соответствии с таблицами 1 и 2 16,18 [2,3]. 18 2. Смещая пальцы вниз, определить положение угла грудины (место несколько ниже манубриостернального сочленения, у взрослых -консолидированного), непосредственно рядом с которым или несколько ниже его при смещении по горизонтали Зарегистрированные по этим схемам ЭКГ необходимо промаркировать "по Мейсону-Ликару", "по Хану" или "по Лунду", поскольку имеются сведения о неполном соответствии между ЭКГ со стандартным и смещенным положением электродов [8,[12][13][14]. ...
... При определении мест установки грудных электродов рекомендуется обратить внимание, что узкий промежуток между ключицей и I ребром не является межреберным промежутком 16 [3,[15][16][17][18]. ...
Russian Society of Cardiology (RSC)
Developed with the special contribution of the Russian Functional Diagnostics Association, Russian Holter Monitoring and Non-invasive Electrophysiology Society, Russian Pediatric Cardiology Association.
... If it is performed or interpreted by inexperienced professionals, it may lead to incorrect results, and patients may therefore be treated incorrectly. A very frequent error in ECG is the wrong or inverted position of the peripheral electrocardiography leads, providing incorrect results and interpretations, including the deviation of the cardiac axis to the right, suggesting pulmonary hypertension or even dextrocardia (Rosen et al., 2014). Dextrocardia presents with specific ECG findings, which may cause problems, leading to incorrect diagnosis and unnecessary cardiac procedures. ...
Dextrocardia with situs solitus is a rare disorder caused by embryological malformation. It may be asymptomatic and overlooked when isolated, or when it presents with different symptoms and clinical signs associated with other cardiac and extracardiac malformations. The present article describes the radiologic, electrocardiographic, and echocardiographic findings of a Pitbull dog with isolated dextrocardia and situs solitus.
... If it is performed or interpreted by inexperienced professionals, it may lead to incorrect results, and patients may therefore be treated incorrectly. A very frequent error in ECG is the wrong or inverted position of the peripheral electrocardiography leads, providing incorrect results and interpretations, including the deviation of the cardiac axis to the right, suggesting pulmonary hypertension or even dextrocardia (Rosen et al., 2014). Dextrocardia presents with specific ECG findings, which may cause problems, leading to incorrect diagnosis and unnecessary cardiac procedures. ...
Dextrocardia with situs solitus is a rare disorder caused by embryological malformation. It may be asymptomatic and overlooked when isolated, or when it presents with different symptoms and clinical signs associated with other cardiac and extracardiac malformations. The present article describes the radiologic, electrocardiographic, and echocardiographic findings of a Pitbull dog with isolated dextrocardia and situs solitus.
... On other occasions, in spite of ongoing morphological similarities in the two sets of leads (aVR-aVL-aVF and V1-V2-V3, respectively), the QRS morphology in an anterior chest lead can show subtle dynamicity such as an R wave can change to a qR complex or a Q wave can become an rS complex. Lead placement on the chest wall is rarely precise [11,12]. The most common mistake is positioning V1-V3 one or two interspaces too high; an error that is routinely perpetrated by ECG technicians as well as doctors including cardiologists and cardiology fellows [13][14][15]. ...
According to conventional teaching, the limb leads in the electrocardiogram (ECG) represent the frontal plane electrical vectors of the heart, whereas the chest leads signify the horizontal plane. The anterior chest leads V1-V2-V3, however, also have strong frontal plane representation which can result in morphological similarities in these leads to the augmented unipolar leads of the Einthoven triangle. This review highlights the significance of recognizing V1-V2-V3 as not only horizontal, but also as frontal plane leads. Appreciation of this phenomenon helps elucidate a colorful variety of clinically important but seemingly bizarre ECG manifestations that could not be explained otherwise.
... The ECG and the GSR measurements were both sampled at a frequency of 1 kHz via a TMSI Mobita amplifier. The ECG was recorded via 3 leads at the V1, V2 and V3 locations (Rosen et al. 2014). The ground was attached to the participant wrist with a wet electrode wrist band. ...
We investigated and modeled the temporal evolution of motion sickness in a highly dynamic sickening drive. Slalom maneuvers were performed in a passenger vehicle, resulting in lateral accelerations of 0.4 g at 0.2 Hz, to which participants were subjected as passengers for up to 30 min. Subjective motion sickness was recorded throughout the sickening drive using the MISC scale. In addition, physiological and postural responses were evaluated by recording head roll, galvanic skin response (GSR) and electrocardiography (ECG). Experiment 1 compared external vision (normal view through front and side car windows) to internal vision (obscured view through front and side windows). Experiment 2 tested hypersensitivity with a second exposure a few minutes after the first drive and tested repeatability of individuals’ sickness responses by measuring these two exposures three times in three successive sessions. An adapted form of Oman’s model of nausea was used to quantify sickness development, repeatability, and motion sickness hypersensitivity at an individual level. Internal vision was more sickening compared to external vision with a higher mean MISC (4.2 vs. 2.3), a higher MISC rate (0.59 vs. 0.10 min⁻¹) and more dropouts (66% vs. 33%) for whom the experiment was terminated due to reaching a MISC level of 7 (moderate nausea). The adapted Oman model successfully captured the development of sickness, with a mean model error, including the decay during rest and hypersensitivity upon further exposure, of 11.3%. Importantly, we note that knowledge of an individuals’ previous motion sickness response to sickening stimuli increases individual modeling accuracy by a factor of 2 when compared to group-based modeling, indicating individual repeatability. Head roll did not vary significantly with motion sickness. ECG varied slightly with motion sickness and time. GSR clearly varied with motion sickness, where the tonic and phasic GSR increased 42.5% and 90%, respectively, above baseline at high MISC levels, but GSR also increased in time independent of motion sickness, accompanied with substantial scatter.
... Additionally, artifact can occur if ECG leads are placed incorrectly, and mimic pathology like in this case. 8 Proper ECG interpretation depends on several aspects of clinical care. ...
Background: Neurostimulator devices produce electrical oscillations that may prevent accurate diagnosis of an ECG.
The Case: We present the case of a 68-year-old man who came to the emergency department with chest pain and a spinal cord neuromodulator device in situ to treat his polymyalgia rheumatica. A 12-lead ECG was obtained to determine the cause of the chest pain, and atrial fibrillation was wrongly diagnosed.
Conclusion: This case reiterates the value of recognizing this uncommonly encountered ECG artifact to avoid unnecessary mistakes in interpretation of heart rhythms.
... Such studies indicate that special measures should be taken to ensure the correct placement of ECG electrodes, e.g., staff training has been reported to improve electrode placement by 50% [17], while combined training and technical improvements have succeeded to reduce the rate of electrode cable reversals from 4.8 % down to 1.2 % [18]. ECG changes induced by ECG cable reversals have been analyzed in a number of studies [19][20][21][22][23][24]. Methods for the automatic detection of ECG electrode reversals within the limb and precordial set have been proposed, such as: ...
Electrode reversal errors in standard 12-lead electrocardiograms (ECG) can produce significant ECG changes and, in turn, misleading diagnoses. Their detection is important but mostly limited to the design of criteria using ECG databases with simulated reversals, without Wilson's central terminal (WCT) potential change. This is, to the best of our knowledge, the first study that presents an algebraic transformation for simulation of all possible ECG cable reversals, including those with displaced WCT, where most of the leads appear with distorted morphology. The simulation model of ECG electrode swaps and the resultant WCT potential change is derived in the standard 12-lead ECG setup. The transformation formulas are theoretically compared to known limb lead reversals and experimentally proven for unknown limb–chest electrode swaps using a 12-lead ECG database from 25 healthy volunteers (recordings without electrode swaps and with 5 unicolor pairs swaps, including red (right arm—C1), yellow (left arm—C2), green (left leg (LL) —C3), black (right leg (RL)—C5), all unicolor pairs). Two applications of the transformation are shown to be feasible: ‘Forward’ (simulation of reordered leads from correct leads) and ‘Inverse’ (reconstruction of correct leads from an ECG recorded with known electrode reversals). Deficiencies are found only when the ground RL electrode is swapped as this case requires guessing the unknown RL electrode potential. We suggest assuming that potential to be equal to that of the LL electrode. The ‘Forward’ transformation is important for comprehensive training platforms of humans and machines to reliably recognize simulated electrode swaps using the available resources of correctly recorded ECG databases. The ‘Inverse’ transformation can save time and costs for repeated ECG recordings by reconstructing the correct lead set if a lead swap is detected after the end of the recording. In cases when the electrode reversal is unknown but a prior correct ECG recording of the same patient is available, the ‘Inverse’ transformation is tested to detect the exact swapping of the electrodes with an accuracy of (96% to 100%).
... 3 This issue of the Journal contains two interesting articles by Rosen et al., who form part of the research group led by Dr. Adrian Baranchuk, which address the most common mistakes made in daily practice in relation to improper placement of limb and precordial electrodes, as well as tell-tale signs for their detection. 4,5 In this editorial we will elaborate on certain issues directly related to possible errors on performing an ECG. ...
... The proportion of inadvertent electrode reversals is suggested to be higher for the non-routine 16-lead ECG in an emergency setting: 5%, 8%, 8% and 19% for limb leads, standard chest leads, posterior V8-V9 leads and right precordial V3R-V4R leads, respectively [17]. Electrode placement errors can produce prominent changes in the ECG waveform morphology [18][19][20] and pathological patterns mimicking ectopic atrial rhythm, bundle branch blocks, ventricular hypertrophy, ventricular pre-excitation, dextrocardia, simulation or concealing of myocardial ischemia or infarction [21][22][23][24][25][26][27] that might generally result in incorrect data interpretation, erroneous diagnosis and lack of proper therapy if not opportunely corrected [1,8]. The REVERSE mnemonic has been suggested as a useful tool that could be easily followed by the medical staff to identify common electrode placement errors produced by typical abnormal ECG patterns [27], and ECG interpretation in the context of the patient's history is advised [22]. ...
... Extended reviews of the most common cases for 12-lead ECG reversals reveal their typical effect on the P-QRS-T morphology alteration together with some basic principles for recognition of different lead reversals [21,22,24,25,27]. The implementation of these principles into automated lead-switch detection algorithms is a challenging task that has been extensively studied for limb leads. ...
