TRMC Clinical Module 12 Lead EKG Review

Introduction Welcome to the module on How to Perform a 12 Lead EKG and proper routing procedure. This module is designed to update the staff member previously trained in performing EKGs. This module was prepared by: Carol Bradford, BSN, RN, Staff Educator Lionel Machado, RCP, RRT, RT Director Last update 7/20/17

Purpose The purpose of this module is to: Improve lines of communications regarding the ordering, processing, and technical performance of EKGs Assure the timely performance of EKG’s for inpatients and outpatients. Delineate responsibility. Improve the routing of EKG reports back to the physician(s) and patient medical record.

Learning Objectives By the end of the module the learner will be able to: Recall proper placement of 12 lead electrodes to perform a EKG. State the routing criteria and where to find it. Describe the proper documentation following performance of a EKG.

Clinical Procedure Electrocardiogram (GE Mac 5500) Review procedure Electrocardiogram found on the hospital Intranet under “Clinical Procedures” The following slides include key parts of the procedure.

EKG’s An EKG is a record of the electrical activities of the heart. The EKG will only be performed under the order of a physician. The order must be written in the chart or on a prescription pad signed by the MD EKG’s will be the responsibility of ALL staff members trained in this procedure. EKG notification is by the Unit Secretary or nurse per physician order. Routine inpatient EKG’s will be performed within 2 hours of the order Stat EKG’s will be done immediately upon request. phrases that are bold, italicized and underlined, is likely a test question!!!!

Procedure Equipment: 12 Lead EKG machine Electrodes Clippers (for removal of excessive hair) Other pieces of equipment to consider Alcohol swabs to wipe greasy skin Tape to help secure electrodes when they don’t want to stick Face sheet Everyone wants to put pt stickers on the EKGs. The policy does not ask for that. I tell people not to use stickers because it gives them a false sense of security. Many people feel that if they put a sticker on the EKG, then they don’t have to enter the pt information into the machine. This leads to the breakdown of routing.

GE Mac 5500 EKG Machine

Patient Preparation Check chart for verification of MD order Check patient ID name band (2 verifiers) Explain procedure (purpose of the test) Reassure and relax the patient Make sure electrode site is not covered by hair or clothing Place electrodes on patient

Technique Place patient in supine position (the test may be performed in semi-fowler’s position if the patient can’t tolerate the supine position) Place the limb electrodes and leads RA = Right Arm LA = Left Arm RL = Right Leg LL = Left Leg

V Leads Accurately place the V electrodes and leads V1 = 4th ICA at the right of sternum V2 = 4th ICA at the left of sternum V3 = Half way between V2 & V4 V4 = 5th ICA at mid-clavicular line V5 = Anterior-axillary line lateral to V4 (Half way between V4 & V6) V6 = Mid-axillary line directly lateral to V5 (5th ICA) Can not stress this point enough Drill these locations into students. V lead placement is one of the most important issue

V Lead Placement V leads look directly towards the center of the heart. They record the area of heart muscle that they intercept on the way to the center. This diagram shows proper placement.

V Lead Placement This diagram shows proper placement.

Common Errors Placing V5 & V6 on the anterior chest instead of the lateral chest (may miss a lateral wall MI if miss placed) Placing V1 & V2 too high on chest (may miss an anteriorseptal MI) Oily skin, leads not making contact If leg leads are too high (abdomen), may lead to wander

What are we looking for? Anterioseptal Anteriolateral Inferior   AVR V1 Anterioseptal V4 II AVL V2 V5 Anteriolateral III AVF V3 V6 Inferior Inferior Inferior

Equipment Operation Mac 5500 Press ‘ON’ key Press ‘ID key’, enter pt’s ID #, then press Enter Type patient’s name / press Enter Type in Medical Record # (Not the account #) Type patient’s DOB press Enter Choose patient’s sex / press Enter Type in requesting Physician/Interpreting physician If unsure of interpreting physician use the EKG disposition log found on the EKG machine Type your initials & title (i.e. CBRN)/press Enter

Equipment Operation copy Once you have a satisfactory tracing, press EKG key to obtain the EKG (capture data) The machine will automatically print extra copies (if it does not, press COPY). You need a total of 3 printouts. Remember- the machine will prompt you to type in this information (except the interpreting physician, it does not ask for that), add after “dept” MD copy

Technical Pitfalls Artifacts are electrical recordings of muscle movement, uncooperative patients, improper patient preparation, and 60 cycle electrical interference. To correct: Request patient to lie still and relax Re-check all lead hookups and electrode placements Re-check electrical plug outlet Attach limb leads higher on the limb (the more proximal the lead, the less artifact). Wipe down skin (especially if diaphoretic) Remove excess hair (clip) Avoid dry skin (lower legs)

RN Notification Hand one of the “Copy” EKG’s to the patient’s nurse. Do not just place in chart. RN will initial EKG indicating completeness, and then it will be placed in the chart. Pay special attention to EKGs that have the following computer assessment printed on them: Acute Myocardial Infarction Complete Heart Block (3rd degree AV disassociation) Bradycardia or Tachycardia Contact the Physician with the above special indications before the patient is discharged from the area the EKG was performed.

EKG Routing Procedure (I/P and ED) Make sure all appropriate info is keyed into the machine. You need a total of 3 EKGs (original & 2 copies). 1st copy is stamped “Copy” and handed to the RN for review and initialing. The EKG is then placed in the chart. 2nd copy is stamped “MD Copy” and attached to the patient’s face sheet. The 3rd EKG (original) will be paper clipped with the 2nd copy & face sheet and placed on the shelf of the EKG machine. O/P services and O/P EKG’s shall be faxed to requesting physician.

Additional Tips Do not give the patient any information regarding the EKG results. Do not appear frightened by the EKG results. Provide as much privacy as possible, but do not let clothing prevent you from performing the EKG (Shirt/Bra must be removed)

More Tips Don’t forget to use the filter button to decrease artifact Don’t be afraid to repeat a “messy” EKG Keep machine plugged in Make sure the appropriate information is keyed in, and the routing procedures are followed Clean EKG machines daily with germicidal agent.

Thank you for viewing the 12 Lead EKG Review You may now return to take the test. Good Luck!