Introduction

Whether in a community, emergency, or secondary care setting, being able to monitoring and record cardiac function is an essential part of medical practice.  As a result of this, setting up and recording an ECG is a favourite clinical skills station.  Beneath is a quick guide on how to record an ECG, with some extra tips for the OSCE.

 

    Starting off

    A good start should include:

      • Washing your hands
      • Greeting the patient and introducing yourself including your name and position
      • Checking the patient's name and DOB
      • Confirming the patient's details by reading their wristband
      • Explaining what you plan to do and what this would involve
      • Asking the patient's consent for the procedure

       

      For example...

      Good morning, my name's X and I am a final year medical student.  Can I just ask your name and date of birth?  Would it be ok to check your wristband?  Thank you.  I gather you've been a bit poorly recently.  The doctors on the ward have asked me to do something called an ECG with you, sometimes also called a heart tracing.  This would involve you taking off your shirt and sitting relatively still.  I would then place some small sticky pads onto your chest which will be linked up to a machine.  Doing this will give us an idea of how your heart is working.  The reading is relatively quick and is not painful.  Would you be happy to go ahead with this?

       

      Method

      1. Prepare your equipment

      • Check that you have the: sticky pads, ECG machine, ECG wires, ECG print paper
      • Say that you would ideally shave the patient's chest (if chest hair!)

       

      2. Place the sticky pads on the patient

      A total of ten sticky pads are placed on the patient; six on the patient's chest (V1-V6) and four on the patient's limbs (AVR, AVL, AVF, N).  Before placing the chest pads, palpate for the sternal angle (angle of Louis) on the upper sternum, as this corresponds with the second intercostal space.  Counting down from here ensures the chest pads are in the right position.  Placement of limb pads is less precise, however boney landmarks proximal to a joint (e.g. the medial maleolus) are often used.  Further details on pad locations are can be found in the list and diagram beneath.

       

            ECG lead attachment sites

            Sticky pad locations

            Chest Leads:

            V1: 4th intercostal space, right of sternum

            V2: 4th intercostal space, left of sternum

            V3: midway between V2 & V4

            V4: 5th intercostal space, mid-clavicular line

            V5: 5th intercostal space, between V4 and V6

            V6: 5th intercostal space, mid-axillary line

             

            Limb Leads:

            AVR: Proximal to right wrist

            AVL: Proximal to left wrist

            AVF: Proximal to left ankle

            N: Proximal to right ankle

            3. Attach the wires to the sticky pads

            • Pick up the wires and let them dangle (allows the wires to untangle, looking more organised when placed on the chest)
            • Check which lead is which (each should be labelled).
            • Attach the chest leads (work from the patients right to their left (V1-V6))
            • Attach the limb leads (name corresponds to limb)
            1. AVR: Right forearm 
            2. AVL:Left forearm
            3. AVF: Left foot
            4. N: Right foot – Black (Think not the side of the heart)

             

            Often the limb lead are coloured.  If so, the mnemonic Ride Your Green Bike working clockwise round from the right hand can be helpful (Red (AVR), Yellow (AVL), Green (AVF), Black (N)).

             

            4. Get the ECG recording

            • Switch the machine on (machine may ask for patient details)
            • Encourage the patient to lie still
            • Wait for the tracings on the screen to settle
            • Press the print button (should hopefully be clear)

             

              To finish...

              • Thank the patient
              • Uncouple the leads from the pads
              • Ask whether the patient/examiner would like you to remove the sticky pads
              • Look at the ECG!

               

                Things to bear in mind for the OSCE

                Make sure that the machine is plugged in to a power source before you start.

                Inputting patient data into the ECG machine can take up valuable time.  Explaining that you would do this normally or would label the ECG tracing by hand with the time, date and patient details afterwards is normally fine.

                In an OSCE situation the simulated patient may have had several students prior to yourself. Repeated putting on and pulling off of ECG sticky pads may have left his chest with fewer hairs and a little bit sore! Be sympathetic when you put the stickers on.

                Stick the chest pads with the tab facing towards the feet.  This way the ECG wires won’t pull the pad off the body when you attach the clips.

                Don’t panic if you haven’t managed to get any results at the end of the station. Most of the marks are awarded for the procedure itself.

                 

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