CR leads in cardiac emergencies. A preliminary study

CR leads in cardiac emergencies. A preliminary study. R N De Gasperi and D H McCulloh Chest 1991;99;904-910 DOI 10.1378/chest.99.4.904 The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/99/4/904

Chest is the official journal of the American College of Chest Physicians. It has been published monthly since 1935. Copyright1991by the American College of Chest Physicians, 3300 Dundee Road, Northbrook, IL 60062. All rights reserved. No part of this article or PDF may be reproduced or distributed without the prior written permission of the copyright holder. (http://chestjournal.chestpubs.org/site/misc/reprints.xhtml) ISSN:0012-3692

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CR Leads in Cardiac A Preliminary

Study

Raul

M.D.;

N. De Gasperi,

The

and

Emergencies*

David

H. McGulloh,

Ph.D.

of this study

was to find a set of simplified leads that would be useful in cardiac emergencies. In 27 ambulatory cardiac patients and in 15 patients admitted to the hospital, we found that ECG records obtained with six bipolar CR leads were, in most respects, similar to records Obtained previously in the same patients with six V leads. Records obtained with two abdominal-upper extremity leads, tested as possible alternatives to limb leads 2 and 3, were quite similar to records obtained with leads 2 and 3 in patients with an inferior wall infarction. Records obtained with leads CR7, CR8, and CR9 in a patient with a posterior wall infarction revealed a QS pattern that was not seen in the conventional 12-lead hospital record. In patients with anterolateral and inferior myocardial infarctions and in patients with unstable angina, the diagnostic patterns recorded with 11 bipolar leads purpose

(ECG)

electrocardiographic

E

lectrocardiograms diac emergencies

(ECGs) should

mal delay and complexity. require few electrodes, used

in such

recorded be obtained

during with

Because bipolar these leads are

emergencies.

Among

bipolar

carmini-

in this report were ECGs. Although including patients with

tions,

records

I

to

reach

a definitive

ALabdominal

were

heart disease but they were

successfully

during largely

used

approximately abandoned

lion ofWilsons V leads.’3” As part of a plan to develop

in the

diagnosis

of

abdominal

have been used. The

recorded

with

4700,

limb

This comparison cardiac patients

was carried out and in 15 patients

hospital

ofa

because

myocardial

leads

2 and

3.

in 27 ambulatory admitted to the

infarction

or unstable

the

extremities Table

#{149}Fromthe

Department

ofPhysiology

for and

this

Biophysics,

report, University

Miami School of Medicine, Miami. Manuscript received May 14; revision accepted September 24. Reprint requests: Dr. De Gaspeti, UMSM Department of Physiology and Biophysics, P0 Box 016430, MIami 33101

904

is simple

electrode

was

polygraph

(Grass),

the recording were

1 cm).

the of

level

cable checks

grounded

that

the

listed

obtained. where

the

was

with

from

excursion

from

at the

electrical

outlet.

polygraph

all risks

to the

(1 mV

with

only

two

the

right

leg;

A specially

to the

eliminated

DC and

be obtained detached

the

a

to facilitate

range pen

1

exploring

made

was

instrument

Figure

selection

same

could

connected

ofthe

upper

HP electrocardiograph

to provide electrode

and

AL leads

was

input

all were

chest

(frequency

the

records

ground was

repeated

Both

whether

the

0.8

patient table,

patient

and

Recording

TC.

routine

the

AR,

abdomen

AC activity

calibrated

To test

designed current

the

47 cycles/s).

polygraph

and

placed.

using

oflow

approximately

records

model

of the

the

to the

CR,’

first

[HP]

examining to

attached

chest

successively

on the

Using

informed were

while

instrument

of ECG

on the

Packard

afterwards,

HP

their ECGs

Hz), as part

100

position

in place. set

sites

to

electrodes

left

the

the polygraph

studied

suction

illustrates

=

0.05

the

gave

Twelve-lead (Hewlett

reclined

1, a second

Despite differences in the recording equipment used in this study, the tracings obtained with unipolar V leads and with bipolar CR leads were very similar. patients

same

were

electrodes,

of the

below,

patients

study.

Immediately

connected

angina.

In each

response clinic.

in the that

cardiac

in this

an electrocardiograph

at the

cables

in

subjects

frequency

control

electrocardio-

ambulatory

to be

remained

and

the same whether V process of recording

with 1 1 leads, described less than 3 minutes.

Twenty-seven

unipolar

V,-V6

right

Patients

consent

removed;

leads

re-

METHODS

Ambulatory

graph that requires the use of only two electrodes, we decided to test whether records obtained with CR leads, and two abdominal-upper extremity leads, were diagnostically comparable to records obtained with chest

be

our

leads,

two decades,6’2 following the adopa small

would

arrhythmias,

conclusion,

left; AR

ECG tracings and requires

are perhaps the most useful, because the obtained with these leads are very similar to obtained with V leads.9

CR leads

larger

a

results provide preliminary evidence that cardiac potentials may be adequately analyzed by using only two electrodes, using CR and abdominal leads, in succession. The technique described in this report, in which the reference electrode is attached to the right arm, and the exploring electrode is moved successively over nine preselected chest sites and over the umbilicus, can be completed in less than 3 minutes in a given patient, and provides records that are comparable to those obtained with the conventional 12-lead system. (Chest 1991; 99:904-10) quired

CR leads”2 tracings

to patterns recorded number of observa-

identical

12-lead

with

ECG diagnosis would or CR leads had been

chest leads frequently chest

described

patient

and

of developing

leaks.

To compare

amplitudes

obtained

with

obtained

with the

cut and

pasted

the

two

exploring

as a pair,

with

lead

V, was

The

record

oflead

of each methods

electrode

as shown

paired

with

V, was

paired

CR Leads

Q,

waveform, of setting

up

on

the

in Figure

the

tracing

with

in Cardiac

obtained

Emergencies

Downloaded from chestjournal.chestpubs.org by guest on July 10, 2011 © 1991 American College of Chest Physicians

same

2. The

CR2,

etc.

R, etc.

the

The

in rec)rds

leads,

tracings

location record with record

(De Gaspen,

were obtained

lead

CR1.

obtained

McCuioh)

Table

1-Leads:

Placement

Heart

of Electrodes8

Association”

were Chest negative

the

leads:

(C)

To utilize

(reference)

positive

electrode

(exploring)

numbered

The

positions

CR!

Right

CR2

Left

leads

(C: chest;

attached

was

electrode

1 to 9, identical

V

was

to those

on the chest

sternal

border

sternal

Midway

between

chest

midclavicular

line

CR5

Left

anterior

CR6

Left

mid-axillary

line

at same

CR7

Left

post-axillary

line

at same

CR8

Left

mid-scapular

CR9

Posterior leads:

In both

leads,

umbilical

be followed

by the

abdominal

wall.

all CR leads switched

to the

limb

obtained AL.

had

left

lead

lead

A dissecting

to measure fK)iflt

The pair

the

difference

computed if such

and differences

Coronary

Care

ECC

Unit

records

abdominal

upper

At the

hospitaFs

obtained

every

or a HP

To electrode

placed

as possible

the

AL.

over

was

CR

leads

the

lead

that

placed

record

the

anterior after

AR.

was

ofall

was

2 ms;

intervals

of

identified

the

was

amplifiers from

approximately

recorded

amplitude

0.05

3 db per ms.

The

before

2.028

and

after

The

onset

and

in tracings of each

subsequently

an

Computer

The

calibration.

visually

through

extended

at intervals

amplitude

was

connected Il-plus).

pulse,

con-

(Analog

in which

waveform

and

computed.

were

record

different

with

(CCU)

nine

CR

in 15 cardiac ofthejackson

sets

of the

12-lead

of

hospital

was

obtained with V leads. In CR leads, the S wave was significantly smaller 2, and 3, and larger in chest sites

of the

J

in each were

zero.’

with

11 bipolar

two

patients

admitted Hospital.

were

(with

leads

a polygraph

and

Memorial ECGs

control

routinely

a Marquette

ECGs, (Grass),

patients the chest

in the sites

hospital,

described or,

specified

the

amplitudes

with

exploring

by the American

in each

pair

and S waveforms, and relative to the preceding

lead

to determine

leads

between

Q, R, J point

the of the

used

differences

from

for

was and

performed

difference

with

waveform

of these

Patients of the PR

segment, was calculated. The means of these differences and the (t) values of these means’5 were calculated; these are listed in Table 2. In records obtained with CR leads the amplitude of the Q and R waves

was

The

obtained

of each

t tests)

The

over

as an

resolution

records amplitude

AL.

of lead

the

means

leads,

in

time

duration

The

electrocardiograph.

record

waveform

Ambulatory

electrode

waveforms

recorded

served

of each

in the

RESULTS

should

immediately

Q-R-S-T

, several

record,

offset

sequential

surface,

indifferent

with

obtained,

as part

recorded

used

amplifier

bandwith

slope

a 1-mV

the

to lie on

(Mountain

(Apple 3-dB

by

asked

to that

converter

computer

were

each

the

was

attenuation

inscribed

the

that

-

records

To place

electrocardiograph

+ D/A

its

these

was

similar

284J)

on the

alternatives and

thoracic

potentials

amplitudes

Unit

CCU

computer-based

was

attached

in lead

P-R segment.

extremity

1, were

was

(L) arm

of the

electrocardiograph).

Table

electrode left

Patients

Care day,

as CR4

as CR4

the

significantly

were

to the Coronary

level

level

magnification

(paired

were

Potentials

deflection

a 10-fold

calculated;

t tests

octave.

as CR4

used

with

preceding

was

as CR4

level

with

between

of tracings

level

was

isolation

at DC;

transverse

CCU

patient

cm)

model

The

the

All

in bed.

x 3.8 x 1.5

in a desk Hz.

supine

computer-based

to an A/D

started

transverse

AR was

with

paired

amplitudes

to the

relative

installed

response

90

a methodical

then,

paired

microscope

1978,

V leads.

lying

chest,

at the

The

(3.8

circuit

through

of such lead

to record

3 was

Inc.

unipolar

patient

of the

used

of a small

Inc) space

back

Clinic.

as CR4

tested

that

utilized; arm

Ambulatory

4

electrode

over

work,

2 was

with

belief

exploration

been

polygraph

level

to the

were

potentials

In this

side.

The

the

(A).

AL,

3, in the

of cardiac

his right

Devices

transverse

(exploring)

AR and

2 and

exploration

with

positive

chest

to record with

on the

electronic

transv.

transv.

of the abdomen

leads,

at same

and

unipolar

space

(indifferent)

AR,

while

positions,

space 3 and

at same

negative

arm,

electrode

the

sisted

V intercostal

at same

in lead

the

*A}4ominal

line

arm),

as follows:

positions and

line

The

region

to leads

axillary

(R) arm

chest

at IV intercostal

Left

right

right

on

to record

are

CR4

to the

to the

at IV intercostal

border

midline

R: right

placed

used

CR3

Abdominal

in

CR

obtained

a

essentially

similar

J

point

to

was

that

in records

the amplitude of in chest sites 1, 5 and 6. In CR

leads,

the

chest

sites

(AR)

the

than

was

larger

in lead 2, while the S wave than in lead 2. In abdominal-left

significantly extremity lead

(AL)

the

was

significantly

4, 5, and

Q

and

more

measured

R waves

amplitude

negatively

inscribed

6. In abdominal-right were

of the

arm

significantly

R wave

smaller

lower than in limb lead 3. In none ofthe 216 pairs ofrecords

was there

difference

T wave

records Coronary

in making Care

In patients

the

polarity

up each Unit admitted

of

the

in lead

a single between

pair.

Patients to the

CCU,

three

of whom

FIGURE 1. Position of electrodes in CR, AR, and AL leads. In CR leads, the negative electrode is attached to the right arm, while the positive electrode is pasitioned on chest sites numbered 1 to 9. In lead AR, the negative electrode is attached to the right arm, and the positive electrode is positioned on the umbilical region of the abdomen. In lead AL, the negative electrode is attached to the left arm , and the positive electrode is placed on the umbilical region of the abdomen. (Redrawn with permission from Clement#{233} CC. Anatomy. A regional atlas of the human body, 3rd ed. Baltimore: Urban & Schwarzenberg, 1987.)

CHEST

Downloaded from chestjournal.chestpubs.org by guest on July 10, 2011 © 1991 American College of Chest Physicians

i

99 1 4 I APRIL

1991

905

H

I:F

#{149}1 2. ECG tracings recorded with conventionally used leads (2, 3, V1-V6) and with bipolar leads (AR, CR1-CR6) described in “Methods,’ in one of 27 ambulatory cardiac patients; the records obtained the exploring electrode on the same chest site were pasted together in ‘pairs,” Ic, the record obtained with lead CR! was paired with that obtained with lead V,, lead CR2 with lead V,. etc; the record obtained with abdominal-right arm (AR) lead was paired with the record of lead 2, the record obtained with abdominal-left arm (AL) lead was paired with the record of lead 3. The R waves in chest positions 4, 5, and 6 were almost identical in CR and V leads; there was a lesser degree of similarity of the S waves in chest position 1. In chest positions 1 and 2, the J point was inscribed at a higher level in CR leads than in V leads; in chest positions 4, 5, and 6, the J point was inscribed at a lower level in CR leads than in V leads. Although the differences in amplitude of the J point for positions 4, 5, and 6 were statistically significant (see text), the means of the differences were less than 1 mm . The polarity of the ST segment and of the T wave was identical in every single “pair” of CR and V leads. FIGURE

AL, with

are

illustrated

pattern

was

Table

Q-wave

in Figures essentially

2-Means

S-wave J-PR

than

tx

=

than 906

Paired

and the CR3-V3

(t)

of

V leads.

The

anterior

ventricular

QS pattern wall

Values (CR Leads-V fr,ad) ofAmplitude Value ofThese Means (tXiStandard CR4-V4

CR5-V,

CR6-V6

of a transmural was

lesion

demonstrated

(in mm; 10 mm Error of Mean) AR-Lead

in the

equally lmV)

2

by of

AL-Lead

0.00

0.00

0.00

-0.02

-0.07

-0.05

-0.21

-0.20

(t)

0.00

0.00

0.00

-1.02

-1.55

-1.14

-2.68t

-1.82

X

0.00

-0.43

-0.28

-0.53

-0.43

-0.25

-3.18

-2.05

(t)

0.02

-1.36

-0.76

-1.10

-1.00

-0.49

-5.30t

-3.61

X

-4.86

-4.39

-1.M

0.37

0.79

0.95

0.72

(t)

-6.84t

-5.83t

-2.66t

1.18

2.96t

4.17t

2.45t

0.18

-0.08

0.11 1.41

negative

in records

tSignificant

between

point)

CR2-V,

(t)

) The

diagnostic

of CR and

CR1-V1

X

*(

5, the

in records

(X) ofDifferences Waveforms (Q-R-S-J

Xt

R-wave

3 through similar

sign obtained

difference

1.30

preceding with between

a mean conventional the

two

the mean of differences of amplitudes, 1 mm, ie, relatively very small.

-0.39

-0.54 value leads methods

that,

(unipolar ofsetting-up

in records

chest

V leads

the

in millimeters,

-0.69

-5.60t

2.20t*

indicates

measured

-0.78

obtained and

limb

leads

leads 2 and

CR,

0.5! 1.52

-0.05

-4.64t

using

0.19

-0.39

AR and

AL,

the

S wave

in the

3

1.54

waveforms

were

smaller

3).

leads.

is, with

the

exception

of the

CR Leads

#{149}in Cardiac

anterior

Emergencies

Downloaded from chestjournal.chestpubs.org by guest on July 10, 2011 © 1991 American College of Chest Physicians

precordium,

(De Gasper

less

McCu!loh)

CR1

y9

:trt . ‘I’F+#{149}l

CR4

!H

,

‘\.

CR5

CR2 HT

AR ‘

v*-fl--

FIGURE

iij :

:..

CR3

:i

.

.

:

:

tracings

recorded

electrocardiograph

with in

a digital

a patient

corn-

who

had

developed an acute anterior wall myocardial infarction confirmed by echocardiography, thallium uptake, and multiple gated acquisition (MUCA) studies. The records obtained with CR, AR, and AL leads are Linretouched photographs of the data displayed in a large monitor; these records are arranged as in Figure 1, next to records obtained with conventional ECG leads. The R waves are absent in records obtained, with bth methods, in chest positions 1 to 5, and in lead AL, which is compared with lead 3.

. CR6

_

AL

ECG

3.

puter-based

#{149}:

both methods in anterior precordial leads and is illustrated in Figure 3; the ST segments were nearly identically elevated in records obtained with CR and V leads in chest positions 2, 3, 4, and 5. In oe patient

CR4.

Ri

--

CR7

who

had

and

an ejection

repeated

in records

shown

LLLt’-

the

ischemia a depressed

obtained

with

lead

AL,

ST

in records and V. (Fig by inferior 5, are also in which

the

electrode was placed on the umbilicus ofbeing attached to the left leg. In all patients,

records

of lead

2 were

almost

identical

to records

the exploring elecinstead of the left

leg. In records

was

obtained

myocardial left ventricle, absent

shown

FIGURE 4. EcG records obtained in a patient who had developed an acute postenor wall myocardial infarction, confirmed by resting thallium uptake and echocardiograph) The curvilinear polygraph tracings were recorded with twice their normal sensitivity Where pairs of records appear (V leads and CR leads 1 to 6), the tracings are quite similar. Leads CR7, CR8, and CR9 recorded with the electrode Ofl the postenor left hemithorax revealed a QS pattern not seen in any ofthe other leads used conventionally. Unpublished studies ofECG records o1)taifled with CR leads (1 to 9) in 51 normal adult men showed that the R wave was inscribed in all leads in every one of these subjects.

percent,

obtained with lead AR, in which trode was placed on the umbilicus

acute ofthe

V

ofsubendocardial of2O

segment was displayed almost identically ofleads CR5 and V5 and in records ofCR6 5). Electrocardiographic changes caused wall lesions, and shown in lead 3 in Figure exploring instead

Lc

episodes fraction

in the

in Figure

in a patient

infarction shown

who

suffered

an

of the inferoposterior wall in Figure 4, the QS pattern

12 leads

used

4, it became

in the

apparent

CCU,

but,

in leads

as

CR7,

CR8, and CR9, in which the exploring electrode was placed on the posterior regions ofthe left hemithorax. The voltage in anterior leads (chest positions 1, 2, and 3) was increased in CR and V leads and the polygraph’s amplifier was set to record at twice the normal sensitivity (1 my = 20 mm vertical deflection). DiscUSSION

Ambulatory The

Patients

differ”nces

between

amplitude CHEST

Downloaded from chestjournal.chestpubs.org by guest on July 10, 2011 © 1991 American College of Chest Physicians

I 99

values I 4 I APRIL,

ofQ 1991

and 907

11/5/8

4 CR1

vi

V4

CR4

..

ftT

‘4

I

II#{149}I AR

CR2

1iiL.

CR5

V5

AL

:v31

CR6

t16

CR3

I

-

.

FtcuRE 5. The patient, whose ECG records are shown in this Figure, had suffered several myocardial infarctions; a chronic unstable angina persisted. In these records, the ST segment was inscribed below the preceding PR segment in records obtained with leads V, and V6, and is equally visible with leads CR5 and CR6. The Q wave was recorded with both lead 3 and lead AL. This Q wave was shown to exceed 50 ms in duration in tracings recorded with the polygraph at a speed of 100 mm/s. The fact that this patient had a very low ejection fraction (20 percent) could be explained by the long history of repeated infarctions, presumably in the subendocardial layers; the finding that R waves were prominent throughout the circumference of the left hemithorax, including the posterior regions, sugjests that the subepicardial layers of the ventricular myocardium were still intact. Echocardiograms and multiple gated acquisition (M UGA) studies revealed a global hypokinesis, with alcinesis of the anteroapical and lateral segments.

R waves

recorded

sponse agrees used in

with

despite

significant

of the with

the waveforms placed on the

and

difference

instruments

used

studies

to compare these studies

CR

the

in which CR and revealed

the

V leads in in

were

not

frequency this

same

study.

reThis

defects.

was

The tentials

instrument

V leads; the figures published a remarkable similarity

when the same chest

exploring site.8”6”7

electrode In a study

It would be useful to reexamine leads in patients with arrhythmias

of was that

with V leads, concluded that

position. correctly

“since no important variation was found in abnormal conditions in the precordial the CR or the V leads, we think there

in normal nor leads using is no practical

criteria,

different precordial and Gonzalez-Tamayo9

advantage in preferring to be recorded.”

the

latter.

CR

leads

are

easier

of routinely of the chest

exploring cardiac was demonstrated

p0in

this study, by finding a QS configuration in a patient with a posterior ventricular wall infarction only in leads CR7, CR8, and CR9, but not in any other chest

leads

compared the Meneses-Hoyos

importance at the back

the value of CR and conduction

the

Although diagnosed none

physicians this

ofthe

QS pattern. Cardiac potentials

at the hospital CCU had lesion with classic ECG

12 conventional that

leads

develop

chest have been systematically designed to draw body surface been neglected in routine clinical

had

at the recorded 121

scalar

back

revealed of the

in studies but they have electrocardi-

CCU

Patients

ography.

In leads leads.

these patients, the records obtained with CR were almost identical to those recorded with V In each case, the correct diagnosis was made only the CR leads.

on the use of unipolar leads in which the exploratory electrode was placed on the back of the chest) Unpublished measurements, made in this laboratory, ofthe amplitude ofthe H wave in CR7, CR8, and CR9

using

908

There

are

CR Leads

relatively

in Cardiac

few

Emergencies

Downloaded from chestjournal.chestpubs.org by guest on July 10, 2011 © 1991 American College of Chest Physicians

published

(De Gasperi

reports

McCuioh)

in 51 normal

men

in these

leads

pattern evidence ventricular

in

reveal

the of a wall.

The

the

inscribed A QS

leads may be considered lesion in the posterior

with

Leads

preferential

use

leads

CL

the R wave in records show unequivocally were

very

over

other

CL,

several leads in

and

CF

in all pairs

of CR

and

V leads

across

similarity

of R waves

in both

methods

is in

contrast with the differences in amplitudes of S waves; values measured with leads CR1, CR2, and CR3 leads were significantly smaller than those measured with

chest-

leads,

advantages 100 normal

similar

of CR and V leads. Our results that the peak positive voltages

the chest.

Leads

CF) was first advocated and Wood and Selzer.6

of CR,

noted CR

CF and

of CR

(CL and Groedel,5

studies

and Barnes7 obtained with

was

exception.

This

extremity leads Roth,3 Larsen,4 comparative

R wave

without

posterior transmural

of CR

Comson

that

in all subjects,

by In

Deeds

in records subjects: in

leads leads values

Vi, V2, and V3, while S waves CR5 and CR6 were significantly measured with the corresponding

The central

validity terminal

of Wilsons concept, (CT) is the best

measured larger V leads.

namely placement

with than

that the for the

such records, the P wave was usually upright, the amplitude of the R wave was larger, and there was less deviation of the ST segment from the level of the

indifferent electrode, was, at one time, a subject of heated controversy. It was eventually demonstrated that, although the potential at the CT did not remain

preceding PR segment. HechE#{176}noted that the potential right arm were of lesser magnitude

at zero variations

than in other extremities, slightly influenced by QRS

variations and more

and that these axis deviations,

were unless

deviation was extreme. It was also noted waves had a higher amplitude in CR than this was attributed to the relative to the precordium. Dolgin

et

confirmed

alh6

negativity The that

the

wave was larger in records of CR obtained with V leads, regardless the

QRS axis. It is important

of the

lead

of the

ventricular

to note

vectors

that

of the right data published amplitude

R

leads than in those of the direction of

similar front,

arm by

of the

the polarity to the

during the depolarization of the heart, at the CT were of a lesser magnitude recorded

finding

right

lent

support

obtained with CR leads was obtained with the to the

central

CR

leads,

arm,

left

arm,

to Wilsons

or left

leg.

proposal

that

were said to be similar to what reference electrode connected

terminal. for

reasons

diagnostically where the

electrodes

from

at the has

the than

V leads are the precordial leads of choice. In addition to numerous clinical studies that relied on CR leads for diagnosis and treatment,’’2 these leads have been used to draw body surface maps;’8 the shape and distribution of the isopotential lines

considered emergencies

polarity

as it proceeds

those This

only such

that the R in V leads;8

in CR leads,

is essentially activation

in the uniform

is a critical

discussed

above,

can

be

useful, especially in cardiac time required to position the factor

in recording

an ECG.

endocardium to epicardium. In subjects in whom the activation front proceeds from left to right during the initial depolarization ofthe septum, the polarity of CR leads is, during a very brief interval, opposite the

In an emergency, reference electrode

polarity of the septal activation front. In lead AL (abdominal-left arm lead), proposed in this article, the lead axis is directed from left to right and downward;

three electrodes to three extremities to set up the central terminal; as the preliminary results reported in this study indicate, this simplification of the tech-

lead AL may depolarization.

nique

Records ventricular careful large

be

optimal

obtained with hypertrophy

ofCR

Comparison

Objections leads CR, that the extremities

the

in may right

Leads

this

early

phase

of

CR leads in cases of right should be the subject of

scrutiny, because, positive potentials

right shoulder and ular depolarization.

these cases, be transmitted

arm

with

during

right

relatively to the ventric-

V Leads

magnitude was large

of cardiac potentials relative to potentials

in our subjects, the been a source of error, If,

a significant

difference

amplitude

not

Bipolar

Leads

it is much simpler to attach one on the right arm, than to connect

sacrifice

any

information.

Having

to

record each of several

tracings in an emergency; it suffices to move the exploring electrode, in succession from one point to the next, over the anterior, lateral, and posterior regions ofthe thorax and abdomen, to explore cardiac potentials in all directions in space, while the record is being interpreted in real time. In this study,

CR lead

of

of Using

attach only one exploring electrode to lead at a time does not delay the recording

assessment

in such recorded

potential in the we would have

in the

does

Speed

recording 1 1 bipolar leads than 3 minutes. In a cardiac

raised against the use of chest-extremity CL, and CF were based on the concept

on the chest.’3 right arm has measured

to record

and

Simplfication

of a rhythm in a few

in succession emergency, strip

could

required less a preliminary be

made

with

a

seconds.

ACKNOWLEDGMENTS: The authors are most grateful to persons who made this work possible: Ms. Jorgelina Rodriguez and Ms. Ada Ralls at the JMH Heart Station, Drs. Robert Myerburg, Martin S. Bilsker, Kyriacos C, Pefkaros, and Rafael Sequeira for permission to obtain records at the Division of Cardiology, Mr. Jim Gray for

CHEST

Downloaded from chestjournal.chestpubs.org by guest on July 10, 2011 © 1991 American College of Chest Physicians

I 99 1 4 1 APRIL,

1991

909

the design for preparing computer advice on for revisions Aurora De

of the computerized electrocardiograph, Mr. C. Freites the electrodes, Dr. Wolfgang Nonner for writing the programs used in this project, Dr. Frans Huijing for data analysis, Dr. Henry Gelband and other colleagues of the manuscript, and Ms. Dolores Frills and Ms. Gasperi for editing the manuscript. REFERENCES

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Cardiac Emergencies

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CR leads in cardiac emergencies. A preliminary study. R N De Gasperi and D H McCulloh Chest 1991;99; 904-910 DOI 10.1378/chest.99.4.904 This information is current as of July 10, 2011 Updated Information & Services Updated Information and services can be found at: http://chestjournal.chestpubs.org/content/99/4/904 Cited Bys This article has been cited by 1 HighWire-hosted articles: http://chestjournal.chestpubs.org/content/99/4/904#related-urls Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.chestpubs.org/site/misc/reprints.xhtml Reprints Information about ordering reprints can be found online: http://www.chestpubs.org/site/misc/reprints.xhtml Citation Alerts Receive free e-mail alerts when new articles cite this article. To sign up, select the "Services" link to the right of the online article. Images in PowerPoint format Figures that appear in CHEST articles can be downloaded for teaching purposes in PowerPoint slide format. See any online figure for directions.

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