1. Performing 12 Lead EKGs Emergency Department Union Hospital

2. Contents Overview Management Steps Technique Clinical Competency Form

3. Overview PERFORMING A 12 LEAD Good EKG technique is important for achieving the best result quality. Check the patient is comfortable, relaxed and reassured that the procedure is painless. Each time the heart muscle contracts it generates a voltage pulse. These heart voltages are picked up by electrodes placed on the patient’s skin, but when muscles contract, a voltage pulse also appears, masking the heart voltages that are recorded by the EKG machine. Good technique on your part will help the patient relax.

4. Preparation of the Patient Electrode placement can significantly affect the gravity and slope of the EKG wave form. Ensure limb leads are attached so that the patient remains relaxed. Chest lead placement is very important as the incorrect intercostal space can alter the EKG pattern. V1 and V2 are positioned in the fourth intercostal space on the right and left side of the sternum respectively. V4 is positioned in the fifth intercostal space in the mid-clavicular line. V3 is positioned half way between V2 and V4 following the same line. V6 is positioned in the fifth intercostal space in the mid axillary line. V5 is positioned half way between V4 and V6 in a straight line.

5. Performing an EKG Press M Menu D Directory A Add a new patient

6. Performing an EKG Enter Demographics Department: ER Last Name: Doe First Name: John L REQ#: Leave Blank MR#: 6 digit number Hospital #: 8 digit number Chief Complaint: Chest Pain Age: 99 Sex: Press M or F Attend MD: Blank Order MD: Blank Review MD: DR. seeing patient Tech: Initials- First, middle, last name Room: Tx 5 Comment: Blank Priority: Stat DOB: 2 digit month SPACE 2 digit day SPACE 4 digit year. Press left arrow until back to main screen.

7. Rhythm Strip Change speed on cart by pressing the #7 mm/s. The speed indicator is located in the bottom right of the screen. Default speed is 25mm/s. Press the #7 mm/s once to change from 25 mm/s to 50 mm/s. Press the #3 to change the viewed leads from all to V123. Press the rhythm button. Done. Change setting back to default press #7mm/s until the indicator reads 25mm/s. Press #5 to change leads back to normal ECG. You can also reset by powering machine off.

9. LIMB LEADS

10. EKG Problems Many of the common problems met in taking EKG’s are due to placement or application. Most symptoms of problem EKG’s fall into one or more of the following categories. Powerline(AC Interference) Wandering Baseline Muscle-somatic tremor Intermittent or jittery waveform

11. Technique POWER LINE(AC INTERFERENCE) Common causes Nearby electrical appliances, power cords near the patient Improper grounding of electrical appliances in the area. Loose connections. Insufficient skin preparation. Dry electrodes. Patient touching metal part of bed.

12. POWER LINE(AC INTERFERENCE)

13. Technique TO REDUCE INTERFERENCE: Do not touch electrode during recording. Make sure patient is not touching wall or metal part of bed. Check EKG technique on the arms or chest leads electrodes. If interference is on all your leads the interference is usually from test location.

14. Technique BASELINE WANDER A slow upward or downward motion of any or all lead tracings. COMMON CAUSES: Poor electrode location. Unnecessary movement of patient. Excessive moisture/hair on skin. To reduce Baseline Wander: Have patient relaxed. Arrange patient cable so there is no pull on the lead wires. Check for secure application of electrodes. Discourage excessive movement during test.

15. WANDERING BASELINE

16. Technique TREMOR Tremor is identified by a fuzzy, totally irregular baseline. COMMON CAUSES: A tense patient. Uncomfortable positioning of your patient. To Reduce Tremor: Make sure patient is comfortable. Keep patient as quiet as possible. Check electrodes are making firm contact.

17. TREMOR OR MUSCLE ARTIFCT

18. Technique INTERMITTENT OR JITTERY WAVEFORM Irregular movement of the baseline up or down with no apparent regularity called the jitters. It may have spikes or interruptions in the recording. COMMON CAUSES: Loose connections. Broken lead wires. Dry electrodes. Muscle tension or movement. TO REDUCE INTERMITTENT OR JITTERY WAVEFORM Check all connections. If jitters in 2 limb leads or one or two chest leads, check EKG technique. Test lead wires by jiggling them and watching for effect on EKG. Reapply electrodes.

19. INTERMITTENT OR JITTERY WAVEFORM

20. Tracemaster (old EKG’s) Password:0670 Enter F2 Location 635 Tab ID:MRN Enter If patient has had an old EKG in this system the most recent will be highlighted. F2 to print Print to ……site EnterSite: (00) F5 to accept Print report 12 lead+ RS Enter

21. CLINICAL COMPETENCY FORM PERFORMING 12 LEAD EKG’S Explains the procedure to the patient or assessor Prepares skin for electrode placement Attaches electrodes at appropriate sites Obtains a 12 lead EKG Obtain rhythm strip Changes EKG paper Store/Print/Edit EKG from Pyramis Retrieve prior EKG’s Able to perform STAT EKG in 10 minutes. Name_____________________Date:_______ Assessor______________________ AchievedNot Achieved