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.
A good start should include:
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?
1. Prepare your equipment
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.
Sticky pad locations
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
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
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
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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