Proposed bedside maneuver to facilitate accurate anatomic orientation for correct positioning of ECG precordial leads V1 and V2: a pilot study.

ABSTRACT

BACKGROUND: Misplacement of right precordial electrocardiogram (ECG) electrodes superiorly is a prevalent procedural error that may lead to false findings of T-wave inversion or QS complexes in V2-possibly triggering wasteful utilization of health care resources. Standard technique for proper placement of V1-V2 entails initial palpation for the sternal angle, pointing to the second intercostal space (ICS), followed by lead fixation at the fourth ICS. STUDY OBJECTIVE: Because adherence to this approach may be limited by lack of a visual landmark for the second ICS, we assessed an alternative technique. METHODS: The evaluated technique involved placement of the patient's hand up against the base of his/her neck (H→N maneuver) to help demarcate visually a specific point "X" on the chest. RESULTS: Of 112 patients studied, "X" landed on the first rib in 2.7%, first ICS in 7.1%, second rib in 56.3%, second ICS in 33.0%, and third rib in 0.9%. Thus, in 89.3% (95% confidence interval 83.6-95.0%) of cases (93.3% of men, 84.6% of women; p=0.13), the second ICS could be identified by H→N via the following simple rule Utilize "X" if it overlies an ICS; or the immediately subjacent ICS if "X" overlies a rib. CONCLUSION: The H→N maneuver provides a primarily visual approach to identifying the second ICS and, thereby, the fourth ICS for affixing V1-V2. If the present initial experience is confirmed, H→N might merit consideration as an educational tool to promote anatomically correct placement of these precordial leads, a prerequisite to diminishing the incidence of ECG procedure-related "septal ischemia/infarction."