• Michael H Lehmann and Aimee M Katona.
• Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA.
• J Emerg Med. 2012 Oct 1;43(4):584-92.

BackgroundMisplacement 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 ObjectiveBecause adherence to this approach may be limited by lack of a visual landmark for the second ICS, we assessed an alternative technique.MethodsThe 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.ResultsOf 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.ConclusionThe 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."Copyright © 2012 Elsevier Inc. All rights reserved.

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