5įigure 5: modified Lewis lead placement From: Lewis lead, LITFL, Medical Eponym Library. Cadogan M The notable difference being that the right arm lead is placed over the manubrium rather than the right second intercostal space (Figure 5). 4įigure 4: modified Lewis lead placement From: The Lewis Lead for Detection of Ventriculoatrial Conduction Type Huemer et al, Clinical Cardiology (2016) 39(2) 126-131įinally, Life in the Fast Lane describes another Lewis lead placement type. In this study, the Lewis lead placement was associated with increased AV conduction detection. In this study, leads were configured, as described above, with the right arm electrode was placed in the right second intercostal space and the left arm lead was placed in the right fourth intercostal space (Figure 4). During EP stimulation, standard ECG and Lewis lead ECGs were obtained. In 2016, 47 patients undergoing an electrophysiology (EP) study were enrolled in a study to validate the above placement of the left and right arm leads for a Lewis Lead ECG. 3įigure 3: modified Lewis lead placement From: The Lewis Lead : Making Recognition of P Waves Easy During Wide QRS Koomen E et al, 2009. In this case report the right arm electrode was placed in the right second intercostal space and the left arm lead was placed in the right fourth intercostal space (Figure 3). In 2009, a case report was published utilizing Lewis lead ECG placement to detect A-V dissociation in a wide complex tachycardia. There are several other modified Lewis lead placements have been described since Dr. The common theme among them is that leads are move from the left and right arm to either the right side of the sternum or the sternum itself.įigure 2: Original Lewis lead placement by Sir Thomas Lewis.
There are several options for lead placement outlined below. In both instances the clinician is evaluating evidence of AV disassociation. From a macroscopic vantage point, the Lewis Lead ECG is a practical tool to use when a physician wishes to evaluate for electrical activity from the sinoatrial node. In the setting of a wide complex tachycardia and when atrial fibrillation is in question. Practically speaking the Lewis Lead ECG is used in one of two situations. In this configuration, special attention is paid to leads I and II to look for atrial activity. In the original publication described a “convenient 5 lead placement” about the right atrium (Figure 2) to better detect atrial electrical activity. Originally described by Sir Thomas Lewis in his 1913 publication “Clinical Electrocardiography”, the Lewis lead ECG was originally adapted to better identify p waves in atrial fibrillation, or “auricular fibrillation” as it was called in that publication. You agree and hang up the phone, and think to yourself “A who-lead ECG?”. She asks you to perform a Lewis lead ECG to better evaluate the rhythm while she is charging her Tesla to drive in. She asks if you see any AV dissociation, which is not easily appreciated. You call the patient’s cardiologist and explain what is going on. Remember, with wide complex tachycardia it is important to rule out ventricular tachycardia. As you start to ponder what could be causing this octogenarian’s weakness, your tech hands you this EKG 1: Triage vital signs are unremarkable except for tachycardia at 143. It’s your charge nurse and there’s a new patient arriving and the chief complaint? Weakness… You walk into the room and see an 80 year old male with a history of CAD sitting calmly in the bed. It’s a slow night in a single coverage ED and you think to yourself, maybe now is a good time to take a nap. For a deeper dive on ECGs, we will include links to other great ECG FOAMed!
Heart monitor lead placement series#
Welcome to this edition of ECG Pointers, an emDOCs series designed to give you high yield tips about ECGs to keep your interpretation skills sharp. Authors: Brannon Inman (EM Resident, San Antonio, TX) and Lloyd Tannenbaum (EM Attending Physician, San Antonio, TX) // Reviewed by: Jamie Santistevan, MD ( jamie_rae_EMdoc, EM Physician, Presbyterian Hospital, Albuquerque, NM) Manpreet Singh, MD ( Assistant Professor of Emergency Medicine / Department of Emergency Medicine – Harbor-UCLA Medical Center) and Brit Long, MD ( long_brit, EM Attending Physician, San Antonio, TX)
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