ECG (EKG) Lead Placement
Debbie Kennedy, MS, RN, CHES Staff Development Coordinator, Ohio State University Wexner
Medical Center, Education, Development & Resources Department In Consultation with: Mary Beth
Fontana, MD, Associate Professor Emeritus, Division of Cardiovascular Diseases Department of
Internal Medicine OSU
ECG (EKG) Lead Placement Objectives
Primary Objective: Demonstrate the ability to independently
perform basic ECG (EKG) lead placement.
Secondary Objective: Describe how to place ECG (EKG)
leads on a patient.
EKG Lead Placement: General Overview
In this module you will learn and
be able to:
List the
indications,
contraindications
and complications
of EKG
Describe how to
properly apply
electrodes
needed to obtain
a 12 lead EKG
After you complete the module,
you will:
Demonstrate
proper location
and technique for
EKG lead
placement
Demonstrate
appropriate
professionalism
when performing
EKG lead
placement, which
includes
communicating
and working with
the patient while
performing the
procedure
The term ECG is an abbreviation for Electrocardiogram. You will also see it abbreviated as EKG; the
two abbreviations are interchangeable. In this module, Electrocardiogram will be referred to as EKG.
I have provided you with an overview of what you will learn and be able to do as a result of
completing this module. You will be prepared to perform EKG lead placement skillfully and
demonstrate appropriate professionalism when performing EKG lead placement. Skillful EKG lead
placement will produce an accurate EKG recording for precise interpretation of a 12 lead EKG.
Introduction to EKG
• Diagnostic test
– Measures and records electrical activity of the heart in detail
– Provides different views of electrical activity of heart
• 12 views using 10 electrodes
• Interpretation of EKG can aid in the diagnosis of wide range
of heart conditions and guide initiation of therapy
• Accuracy of EKG tracing and interpretation can be affected
by
– Position of patient
– Skin preparation
– Lead electrode placement
“Because of its broad applicability, the accurate recording and
precise interpretation of the EKG are critical.” JACC 2007
An EKG provides information about the electrical system of the heart from 12 different views using 10
electrodes. It is the most commonly conducted cardiovascular diagnostic procedure for a wide range
of minor and life threatening heart conditions and initiation of therapy. In this module, we will focus on
three aspects of the EKG that you will perform and that can affect the accuracy of the tracing and
interpretation. Specifically these are: position of the patient, skin preparation, and lead electrode
placement. Professionally developed and endorsed evidence-based standards for all phases of the
EKG recording, along with guidelines for interpretation, have been established to ensure a high level
of precision and improve the accuracy and usefulness of the EKG in practice. According to the
Journal of the American College of Cardiology “Because of its broad applicability, the accurate
recording and precise interpretation of the EKG are critical.” Clearly stated, if the EKG is not
performed accurately, the interpretation can be adversely affected.
Anatomy: Heart Conduction System



Electrical activation of heart muscle cells
occurs in sequence

determined by heart’s conduction
SA
system
Node
Sequence of activation produces waves on
EKG
Electrodes and leads produce record of
AV Node
activity

electrodes placed in standard locations

using standardized reference axes
activity recorded

combinations of electrodes are called EKG
leads
First to provide a context for the EKG, we will briefly review the systems of the heart.
•
•
•
•
•
Heart has specialized tissue to support two systems, electrical and mechanical. The electrical
conduction system coordinates the muscle cell mechanical system activity. The result is
cardiac output.
Heart rate is set by a small collection of specialized cells called the sinoatrial (SA) node,
located in the right atrium. It is the heart’s “natural pacemaker”.
SA node automatically discharges, without control from the brain; both atria contract.
Electrical impulse travels through the atria to reach another area of the heart, the
atrioventricular (AV) node, which serves as a relay point
Impulses spread throughout specialized cells and the ventricles contract.
Indications, Contraindications and
Complications of EKG
• Diagnosis of abnormal conduction of impulses through
the heart
Indications
Contraindications
Complications
• Disturbances of normal electrical activity (arrhythmias)
• Abnormalities resulting from genetic factors, chamber
enlargement, chemical imbalances or blood flow problems
• Preoperative assessment
• Severe trauma to the chest
• Uncooperative patient
• None known
Performing an EKG – Initial Preparation
1.
2.
3.
4.
5.
6.
7.
8.
9.
Check physician order and gather machine/supplies
Wash hands upon entering room and before touching patient
Identify yourself to patient
Identify patient by first/last name, date of birth
Explain procedure
Encourage patient to relax and assist
Answer questions about procedure
Remove clothing from waist up; provide privacy
Enter patient data into machine
To prepare to perform the EKG,
1) First check the physician's order and gather the EKG machine and supplies to take to the
patient. 2) Wash your hands upon entering the room and before touching the patient. 3) identify
yourself to the patient, giving your name and title. It is important to work with the patient in a
professional manner to prepare them for the procedure, show respect and compassion and
engage them in helping you with your commitment to excellence in getting the most accurate EKG
reading. 4) Correctly identify the patient by asking them to give you their first and last name and
date of birth. 5) Next, you will explain that you are going to perform an EKG that the doctor has
ordered. Explain the procedure as simply and briefly as possible. Ask the patient if they have ever
had an EKG. Describe the EKG as a test that gives a picture of how the heart is functioning. It is
painless and will take about 10 minutes – more time to prepare to run the test than the actual test.
When it is finished, you will give the printout to the doctor who will interpret the findings and talk
with the patient. Explain how you will prepare the patient for the EKG. Let them know you will be
placing “stickers” on their chest, arms and legs that will be connected to wires to the machine. Tell
them you will need to clean their skin and apply some pressure with your fingers to locate where
to place the leads to get an accurate recording. 6) Encourage the patient to help you get the best
recording by relaxing, lying still, breathing normally and not talking when you are ready to run the
report. 7) Ask the patient if they have any questions and answer as needed. 8) Explain to the
patient that you will need them to remove all clothing from the waist up, give them a gown to put
on, open in the front. Also, you will need their arms and legs exposed toward the wrist and ankles.
Provide privacy and assistance as needed for the patient to get undressed. 9) Once the patient is
ready, reenter the room. Prepare the machine by entering patient data.
Positioning Patient
• Place in supine position
– Head flat or at no more than 45 degrees
– Arms and legs free
• If patient cannot lie flat or at no more than 45
degrees
– Position patient for comfort and document altered
position for EKG
Rationale: position can alter EKG tracing
To begin the procedure for obtaining EKG, you must first position the patient. Position of the
patient can alter the EKG tracing. The standard position of the patient is supine – head flat or at no
more than a 45 degree angle, with arms and legs free. If the patient cannot lie with their head flat or
at no more than 45 degrees, position the patient for comfort. You must make a note of the altered
position in your documentation so that the physician can consider the position when interpreting the
EKG.
Skin Preparation
• It is essential to prepare the skin at the electrode
sites before placing the electrodes
Rationale: for best electrical conduction
- de-fat and gently abrade the skin
- maintain full skin contact with electrodes
The next important step for preparing to place the electrodes is skin preparation. Before applying
the electrodes, each area where you will place an electrode needs to be cleaned. Use an alcohol pad
to de-fat the skin and a dry cloth or 2 by 2 gauze pad to gently abrade the top layer of cells of the
skin. Not only does this ensure full contact of the electrode with the skin for best conduction, but also
can reduce noise and improve the quality of the recorded EKG.
Skin Preparation
Normal
Oily
Diaphoretic
If skin is very oily or
soiled, wash with soap
and water; dry
Briskly rub skin with dry
cloth to dry
Clean skin with alcohol
pad-allow to dry
Briskly rub skin with
alcohol pad-allow to dry
Clean skin with alcohol
pad-allow to dry
Briskly rub skin with dry
cloth or 2x2 pad
Briskly rub skin with dry
cloth or 2x2 pad
Briskly rub skin with dry
cloth or 2x2 pad
This chart describes what is required for skin preparation for three common skin conditions which you
will see in your patients.
At each site where you will place an electrode:
1. For normal skin – clean first with an alcohol pad. Allow the alcohol to dry for the maximum
benefit of de-fatting the skin. When dry, briskly rub the skin with a dry cloth or 2 by 2 gauze
pad to abrade the top layer of cells.
2. For oily or soiled skin – to clean the skin, wash first with soap and water and dry. Next, briskly
rub the skin with an alcohol pad. Allow the alcohol to dry. When dry, briskly rub skin with a dry
cloth or 2 by 2 pad.
3. For diaphoretic skin – to dry the skin, briskly rub with a cloth or gauze pad. Next clean the skin
with an alcohol pad. Allow the alcohol to dry. When dry, briskly rub skin with a dry cloth or 2 by
2 pad.
A special consideration might be hairy chests; separate hairs or clip hairs. Shave only as necessary.
Lead Electrode Placement
•
•
•
•
•
Accuracy of ECG interpretation relies on consistent lead electrode
placement
Four electrodes for limb leads:
– right and left arms (RA LA)
– right and left legs (RL LL)
Six electrodes for chest leads: V1 through V6
Flat against skin
Direction of lead wires:
– may point in any direction
•
•
•
IMPORTANT: maintain full contact of electrode with skin with no
stress/pulling on lead wires
Test electrode adhesive pads to ensure sticky/moist
Before performing, double check that the lead clips/wires are securely
attached and going to the correct electrode
The third important step is lead electrode placement.
1) Accuracy of the EKG tracing and interpretation relies on you correctly and consistently placing
the electrodes. 2) You will place a total of 10 electrodes. 3) There are four electrodes for limb
leads named RA right arm, LA left arm, RL right leg and LL left leg.4) There are six electrodes
for chest leads named V 1 through V 6. 5) Electrodes should adhere to the skin and lay flat
against skin 6) Electrodes may point in any direction as long as they maintain full contact with
the skin when connected and there is no stress or pulling on the lead wires. 7) Electrodes
should have adequate adhesive to be sticky and moist. 8) Before performing the EKG, double
check that the leads clips/wires are securely attached and going to the correct electrode.
Go to the attachments to see pictures of the clips and wires. You will notice that they are labeled
and color coded.
Chest Lead Electrode Placement - Landmarks
• It is essential to use landmarks and
palpate to find and position chest lead electrodes
Rationale:
- Consistent, proper lead electrode placement
- Inaccurate placement of an electrode may lead to
inaccurate waveforms and incorrect EKG interpretation
If lead electrodes cannot be accurately placed as noted,
clearly document the actual location of lead electrode
placement on the EKG.
First, place the chest lead electrodes. Because the accuracy of the EKG tracing and interpretation
relies on consistent and proper placement, it is essential to use landmarks and palpate when
positioning the electrodes. If electrodes cannot be placed in the standard position as described here,
you must clearly document the actual, altered location of electrode placement
Chest Lead Electrode Placement - Palpate
•
•
•
•
•
•
V1
V2
V3
V4
V5
V6
4th intercostal space (ICS)*, right sternal border
4th ICS, left sternal border
equidistant between V2 and V4
5th ICS, at the midclavicular line
at the horizontal level to V4 at the anterior axillary line
at the horizontal level to V4 at the midaxillary line
Locate 4th ICS by finding Angle of Louis @ 2nd rib, or use 1st rib
below clavicle; count down to 4th ICS
The names of the six chest lead electrodes are listed here along with their proper landmarks for
position. When placing the electrodes, you will palpate to find the location of the landmarks and
position the electrodes. Go to the next slide to view the actual position of the electrodes on the chest.
Chest Lead Electrode Placement
Suprasternal Notch
Clavicle
Angle of Louis
Horizontal Plane
As you begin electrode placement on the chest it is important to locate the landmarks by
palpating with the index finger. For V1, find the fourth intercostal space and the right sternal border.
You can locate the 4th intercostal space in one of two ways. The first and preferred for greatest
accuracy is to use the Angle of Louis. The Angle of Louis is the angle between the upper part of the
sternum and the body of the sternum. You can identify it as a bony prominence. Find the suprasternal
notch where the clavicle joins the sternum. Apply pressure as you run your fingers down the sternum
to the bony prominence. This will be the Angle of Louis at the 2nd rib. Find the 2nd intercostal space
and count down to the 4th intercostal space. The second alternative is to locate the 1st rib under the
clavicle and count each rib and intercostal space to the 4th. Take caution using this alternative as
there is more room for error. The 1st intercostal space may be incorrectly identified as above the 1st
rib, directly under the clavicle. Next you will use the same method of palpation to position V2 using
the landmark of the 4th intercostal space and left sternal border. Skip placing V3 and go next to V4.
From the 4th intercostal space on the left, palpate the 5th intercostal space. Locate the middle of the
left clavicle, draw an imaginary line to the 5th intercostal space and place V4 where the two intersect.
Place V3 on a diagonal line between V2 and V4. Skip placing V5 and go next to V6. On a horizontal
plane, or straight line, from V4, move your index finger to locate the point at the mid axilla. Place V6.
Place V5 on a horizontal plane from V4 midway between V4 and V6 (most accurate way to identify)
OR at the anterior axillary line. Note: According to 2007 guidelines, more research study is needed to
determine the effect of breast tissue on EKG. Currently it is recommended that electrodes be placed
under the breast in women, with no change in placement, until additional studies using electrodes
placed on top of the breast are available.
Limb Lead Electrode Placement
•
•
Place on fleshy areas; avoid bony prominences
Position in approximately same location on each limb
– right arm and left arm below elbow,
on lower forearm, inside of wrist
– right leg and left leg; below knee
on lower leg, inside of ankle
If lead electrodes cannot be accurately placed in
standard position, clearly document actual/alternate
location of lead electrode placement
Finish with limb lead electrode placement. Evidence suggests that placing electrodes on the limbs in
a position other than the standard can alter the EKG. The following standards apply to limb electrode
placement: 1) electrodes should be placed in fleshy areas on the inside of the arms and legs, near
the wrist and ankle, avoiding bony prominences 2) electrodes should be placed equidistant from the
heart and in approximately the same place on each limb. If a patient has an amputated portion of the
limb, place the electrode on the fleshy area of the inside of the limb, as distal on the limb as possible.
place the electrode for the opposite limb in the same altered position and record in the notes. Note
standard placement of arm and leg electrodes in the picture.
Final Steps
Explain to
Attach lead
clips/wires
to electrodes
Turn on EKG
machine
the patient
how
important it is
to lie still and
be relaxed
while
recording
Record the
EKG
View of person with EKG lead placement
connected to EKG machine
15
Once you have accurately and correctly placed the limb and chest electrodes, you will attach the lead
wires by fastening the clip of the wire to the electrode. Wires are color coded and labeled for each
arm as LA, RA, for each leg as RL, LL, and for each chest lead, V1 through V6. The physician’s
interpretation can be affected if the lead wires are connected to the wrong electrodes. Turn on the
EKG machine. Explain to the patient you are ready to record the EKG and ask them to help by lying
still and relaxing for just a moment. Record the EKG - you will get a paper printout.
Normal EKG
This picture represents an EKG with a stable baseline and no interference with the recording. It is a
clear tracing that the physician will be able to interpret.
Troubleshooting – What to Look For
• Recognize a technically unsatisfactory tracing
• Identify cause of problem
• Correct problem
– ask for assistance if necessary
• Verify that problem is resolved and EKG tracing is
without interference
• Three main problems are:
– electrical interference
– wandering baseline
– somatic or muscle tremor
If you have not performed the EKG correctly, you will see problems with the tracing. It is important to
recognize a technically unsatisfactory tracing by identifying the cause of the problem, correcting the
problem and verifying that the problem is resolved and the EKG tracing is without interference before
giving it to the physician. Three main problems you may see are: electrical interference, wandering
baseline and somatic or muscle tremor. For each of the main problems, we will talk about how to
identify the problem, the cause and what you can do to resolve the problem.
Electrical Interference
The first problem is electrical interference. You will see that the waveform appears as a very jagged
series of lines running close together.
Troubleshooting: Electrical Interference
• What is the cause?
– Multiple pieces of electrical equipment in use, patient using electrical
appliance, improper grounding, lights
• How do you troubleshoot?
–
–
–
–
–
–
–
Move electrical devices away from bed
Unplug nonessential electrical devices
Turn lights off
Turn cell phone off
Ensure cable is not lying on EKG machine or lead wires are not twisted
If plug, ensure machine is plugged into 3 prong outlet
Move to another room
Electrical interference may have a variety of causes: multiple pieces of electrical equipment in use,
patient using an electrical appliance, improper grounding of the machine (right leg is a ground wire),
lights in the room
To correct the problem, you could do any of the following items listed connected to electrical activity
in the room.
Wandering Baseline
The second problem is wandering baseline. The waveform moves up and down over the course of
the tracing.
Troubleshooting: Wandering Baseline
What is the cause?

Bad lead electrode connection or exaggerated respiratory movements
How do you troubleshoot?

Check all leads and electrodes for correct position


remove and replace misplaced leads or electrodes
Check all lead electrodes for full contact with skin

may have tension on wire that pulls lead electrode away




remove lead electrode and replace
skin may be oily or diaphoretic
re-prep skin and reapply lead electrodes
Have patient breath in and out and hold breath as you run EKG
Wandering baseline is caused by a poor connection between the lead and the skin. To correct the
problem, you could do any of the following items as listed
Somatic or Muscle Tremor
The third problem is somatic or muscle tremor. The waveform shows movement in the form of lines
spiking and running close together.
Troubleshooting: Somatic Tremor
• What is the cause?
– Skeletal muscle movement (eg chills, nervousness,
restlessness, or disease such as Parkinson’s)
• How do you troubleshoot?
– Cover patient if chilled
– Position patient’s hands under hips to quiet movement
– Check with nurse/physician for alternate lead placement
higher on the limbs if movement is not as exaggerated
Causes of somatic or muscle tremor are related to skeletal muscle movement. To correct the
problem, you could do any of the following items as listed to quiet the patient’s movements.
Interpretation
Perform
according to
established
procedures
Provide a
technically
correct EKG
to the
physician for
interpretation
Maximize
diagnostic
accuracy of
the EKG
The EKG is not an exact science. To maximize diagnostic accuracy, the EKG must be performed
according to the established procedures and standards outlined on this module. A technically correct
EKG is best for the physician and the patient.
Completion
• Take the clear EKG tracing to the physician
• Remove electrodes and assist patient to sitting position
– determine patient’s tolerance of procedure
• Discard supplies
• Wash hands
• Document
*Once you have completed the recording and before you remove the electrodes, you will take the
clear tracing to the physician. The next step will be to remove the electrodes and help the patient sit
up and get dressed if needed. Check with the patient to see how they are feeling. Finally, you will
discard supplies. Remove the machine from the room. Wash your hands and document that you
completed the procedure, any deviation in position or lead placement from the standard and how the
patient tolerated the procedure.
Pediatrics
• Same procedures and standards would be used
for children and infants.
EKG Lead Placement Skill Checklist
• Review the steps for EKG Lead Placement by reviewing
the attachment:
– Skill Performance Checklist - EKG Lead Placement
• Note: critical and non critical behaviors
– Critical behaviors (in bold type) are those that if
performed incorrectly may directly affect the safety of
the patient or the outcome of the procedure
– Non critical behaviors (in non bold type) are those
that if performed incorrectly may or may not affect
the outcome of the procedure
Go to the attachment: Skill Performance Checklist for EKG Lead Placement and review the steps for
EKG lead placement.. It shows you at a glance the steps outlined in this module for EKG lead
placement by defining the critical and non critical behaviors you will be expected to perform in the
skills check off. Critical behaviors are those that if performed incorrectly may directly affect the safety
of the patient or the outcome of the procedure. Non critical behaviors are those that if performed
incorrectly may or may not affect the outcome of the procedure.
Video: EKG Lead Placement Procedure
 Watch the video which shows the performance of the
procedure – 15:20 minutes. Thank you.