Pre-Op EKG on a Patient Who Can't Lie Flat
You must obtain a 12-lead EKG before surgery on a 74-year-old woman with severe kyphosis and advanced COPD. She cannot lie supine; she sits at about 45 degrees and becomes breathless if lowered further. She has a left-sided mastectomy with scarring and a port in the right upper chest. She is anxious, her hands are cold, and she keeps apologizing. The surgeon's office needs the tracing within 30 minutes. Her blood pressure is 138/84, pulse 92 and regular, respirations 24.
1. How do you adapt lead placement and patient positioning while keeping the tracing interpretable?
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Positioning: Do not force her flat. Document the semi-Fowler's (≈45°) position with the tracing - position alters the axis and can change the appearance of the tracing, and the reader needs to know. Support her arms so they rest without tension.
Chest leads: Standard V1–V6 positions may be impossible on the left because of mastectomy scarring. Place electrodes on intact skin as close to the standard positions as possible, avoid scar tissue and the port site, and label any deviation (e.g., "V4–V6 placed 2 cm lateral to standard due to surgical scarring"). Consistency matters more than perfection; the reader interprets a labeled, reproducible tracing.
Limb leads: Place on the arms/legs per standard, avoiding the port site and any IV. If the left arm is unusable, note the alternative site.
Do not place chest electrodes over the port, over breast tissue in a way that loses contact, or on scarred, non-conductive skin.
2. Her hands are cold and she is anxious. How does that affect the tracing, and what do you do?
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Effect: Cold, clammy skin raises impedance and produces a poor signal - low-amplitude complexes and a noisy baseline. Anxiety increases muscle tension (somatic tremor) and can raise heart rate, which will show on the tracing and should be noted as a contextual finding, not hidden.
Actions:
- Warm her hands (blanket, warm water if available) and let her rest a moment.
- Prepare skin: gentle abrasion, fresh electrodes, good adhesion.
- Ask her to relax her arms and breathe normally; reassure her - a calm patient gives a cleaner tracing.
- Repeat if the first is unreadable rather than submitting a poor tracing.
Document the conditions (cold extremities, anxiety, position) so the interpreting provider knows the context.
3. You have 30 minutes and the first tracing is technically poor. What is your decision process?
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Prioritize a diagnostic tracing over speed, but communicate.
- Quickly identify the problem (impedance? position? movement? lead contact?).
- Fix the highest-yield issue first - usually skin prep and electrode contact - and repeat immediately; a repeat takes only seconds.
- If still poor, obtain the best available tracing, label the limitations clearly, and send it with a note that a repeat may be needed.
- Call the surgeon's office if you cannot produce a diagnostic tracing in time - a technically limited tracing delivered on time with a phone call is better than a silent delay. Do not let the clock push you into sending an unlabeled, uninterpretable strip without flagging it.
Principle: Never submit a tracing you know is non-diagnostic without telling someone; the interpreting provider must know what they are reading.