JPP Letters

Dear Editorial Team,In your latest issue of the Journal of Paramedic Practice (Volume 10, Issue 9; September 2018), there was an article titled ‘Recognising ECG Landmarks’ written by Karen Simpson-Scott. I would firstly like to state that this was a well written article, and an enjoyable read; however, there are some concerns with the information/images within, that I feel require your urgent attention.Figure 1, images 1 and 3 show incorrect limb lead/chest lead placements as otherwise correctly described in the article text. Where possible, upper limb leads should be placed proximal to the wrist and, ideally, on a bony prominence. Lower limb leads should be placed proximal to the ankle, again ideally, on a bony prominence. These standardised positions are ‘best practice’ as suggested by the Society for Cardiological Science and Technology (SCST) for obtaining an accurate electrocardiogram (ECG), but also as a standardised approach for serial ECG comparison, which may potentially be between different users and/or settings (i.e. hospital, ambulance, community, practice, etc). Ideally, any variation should be documented on the ECG trace. Image 3 shows incorrect chest lead placement. V1 and V2 are depicted proximal to the 2nd intercostal space, and too far from the border of the sternum. This therefore disrupts all other lead placements. Correct placement images can be found within SCST guidance.On page 397 in the ‘Chest Lead’ section, there is a sentence that states ‘the third intercostal space should be in line with the angle of louis’. This is incorrect information. The second intercostal space is lateral and slightly inferior to the sternal angle. Once the second intercostal space is palpated, it is then possible to palpate down to the third, and then to the fourth intercostal space. Where the fourth intercostal space meets the sternum, is where V1 and V2 are correctly placed respectively. As already identified in the article text, incorrect chest lead placement can present the clinician with abnormal morphologies, obscuring accurate interpretation of a 12-Lead ECG.I feel that this information should be reviewed and appropriately communicated in a subsequent issue (or other means) so that best practice for paramedics is continuously promoted, and that the images in this article support and reflect the hard work of the text written within.Should you require it, here is the link to the SCST Guidance for Recording a Standard 12-Lead Electrocardiogram (issued September 2017) for any further information and/or clarification: yours,Philip Poskitt

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