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ECG electrode placement 12 lead position anatomy

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Here is a complete, textbook-sourced answer on where the ECG electrodes are placed:

ECG Electrode Placement - Standard 12-Lead

Precordial (Chest) Leads - V1 to V6

Precordial lead placement V1-V6 on chest
Full 12-lead ECG electrode placement diagram
LeadPosition
V14th intercostal space, right sternal border
V24th intercostal space, left sternal border
V3Between V2 and V4 (diagonal)
V45th intercostal space, midclavicular line
V5Same horizontal level as V4, anterior axillary line
V6Same horizontal level as V4/V5, midaxillary line
Key landmark tip: Start at the sternal angle of Louis (manubriosternal junction) - the rib space immediately below it is the 2nd intercostal space. Count down to the 4th for V1/V2, and to the 5th for V4.

Limb Leads (4 electrodes)

ElectrodeStandard placement
RA (Right Arm)Right wrist (distal to shoulder)
LA (Left Arm)Left wrist (distal to shoulder)
RL (Right Leg)Right ankle (ground electrode)
LL (Left Leg)Left ankle
Electrodes may be moved more proximally (e.g., to shoulders/thighs) if necessary due to amputation or injury, with a notation made on the ECG.

Important notes

  • V5 is the most sensitive single lead for detecting myocardial ischemia during anesthesia and exercise testing.
  • V3/V4 may be preferred for detecting postoperative ischemia in high-risk vascular surgery patients.
  • Misplacement is common - studies show up to 50% of clinicians misplace V1/V2. Always count ribs from the sternal angle, never guess.
  • Mason-Likar modification (used by paramedics/monitors): limb leads are moved to the torso (infraclavicular fossae for arms, iliac crests for legs), but precordial placement stays the same. This can cause a rightward axis shift and reduce inferior Q waves.
Sources: Roberts and Hedges' Clinical Procedures in Emergency Medicine, Fig. 14.4 | Miller's Anesthesia 10e, Fig. 32.4 | Pfenninger and Fowler's Procedures for Primary Care
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