1. TRMC Clinical Module
12 Lead EKG Review

2. 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

3. 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.

4. 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.

5. 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.

6. 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!!!!

7. 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.

8. GE Mac 5500 EKG Machine

9. 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

10. 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

11. 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

12. 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.

13. V Lead Placement
This diagram shows proper placement.

14. 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

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

16. 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

17. 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

18. 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)

19. 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.

20. 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.

21. 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)

22. 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.

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