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Use of filter

The filter should not be used for the initial recording as it will distort the ECG. The Society for Cardiology Science and Technology advises the use of the filter only once other efforts to reduce interference, for example attempts to relax the patient and promote their comfort, have been exhausted (SCST 2006). Use of the filter should be clearly identified on the ECG.

Specific patient preparations

Female patients

Placement of the lateral chest leads (V4, V5 and V6) is by convention under the left breast. Whilst there is emerging evidence to support the positioning of these electrodes over the breast, it is currently insufficient to suggest a change of procedure (SCST 2006).

Dextrocardia

Dextrocardia is used to describe a heart that is located within the right side of the chest rather than the left. It may be associated with the condition situs inversus where all the patient’s organs are in a mirror image position.

The following are recommended by the SCST (2006).

Patients with an unknown dextrocardia

The initial ECG recorded in the standard arrangement will show an inverted Pwave in lead I (Paxis >90°) together with poor Rwave progression across the chest leads. If suspected, a second ECG should be recorded with the chest electrodes positioned on the right side of the chest using the same intercostal spacing and anatomical landmarks. This approach will provide a ‘true’ ECG representation. The limb lead complexes will continue to appear inverted, demonstrating the abnormal location of the heart. However, the repositioned chest leads will now show the appropriate Rwave progression. Both ECGs should be retained for inclusion in the patient’s notes.

Patient known to have dextrocardia

The ECG should be recorded with the limb leads in the usual position and the chest lead should be placed across the right side of the chest. Note that swapping of the right and left limb leads will ‘normalize’ the appearance of the limb leads.

When swapping leads, it is imperative that the ECG is clearly annotated to describe the new positions of the electrodes (for example, V3R, V4R, etc.) to prevent possibility of dextrocardia being overlooked.

If there is difficulty attaching the ECG sticker, see Problemsolving Table 12.2.

Table 12.2 Blood pressure cuff sizes for mercury sphygmomanometer, semi-automatic and ambulatory monitors

Indication Bladder width × length (cm) Arm circumference (cm)

Small adult/child 12 × 18 <23

Standard adult 12 × 26 <33

Large adult 12 × 40 <50

Adult thigh cuff 20 × 42 <53

Reproduced with permission from Williams et al. (2004).

Procedure guideline 12.2 Electrocardiogram

Essential equipment

ECG machine with chest and limb leads labelled respectively, for example LA to left arm, V1 to first chest lead

Disposable electrodes

Swabs saturated with 70% isopropyl alcohol to cleanse and prepare the skin prior to electrode placement

Abrasive strips

Alcohol handrub

Preprocedure

Action Rationale

1 Wash hands using bactericidal soap and water or bactericidal alcohol handrub, and dry. To minimize the risk of infection (Fraise and Bradley 2009, E).

2 Explain to the patient that the ECG is to be taken, that it is not a painful procedure and that it will be useful to aid diagnosis. To ensure that the patient understands the procedure and gives their valid consent (NMC 2008b, C; Roberts 2002, E).

3 Ensure that the patient is comfortably positioned either lying or sitting (preferably in semirecumbent position). Any variations to standard recording techniques must be highlighted on the trace, for example ‘ECG recorded whilst patient in wheelchair’. To ensure optimal recording and comfort of the patient (Roberts 2002, E). The ECG may vary depending on the patient’s position so it is important to note this on the ECG (SCST 2006, C).

4 Clean limb and chest electrode sites (see Figure 12.7). If necessary, prepare skin by clipping hairs or use abrasive strip. To ensure good grip and therefore good contact between skin and electrode which results in less electrical