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Jason's Blog: ECG Challenge of the Week for July 15-22. What has happened here?

jer5150's picture

Patient’s clinical data:  Symptomatic 49-year-old white man who presented to the emergency department (ED) with left-sided chest pain.

At the time of admission, there were two consecutive 12-lead ECGs initially performed in the ED.  The above ECG was the second of the two that was performed.   Why would there be a mandatory need to perform a minimum of two ECGs on this type of a patient?   

** *** Both of these images are from the same patient.  Please note that the patient’s chest film was performed correctly and is anatomically accurate (i.e., situs solitus) *** **

I’ve included the chest X-Ray (CXR) because it, by far, provides more clarity than an ECG alone ever could.

Questions:
(1.)  What emergent event has brought this patient to the emergency department?
(2.)  What has produced this unusual combination of QRS axis and precordial pattern?

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jer5150's picture
Submitted by jer5150 on

The 12-lead ECG was performed in the emergency department on a patient having an acute inferior infarction. Initially, the technician performed a "standard" ECG. Upon completion of the first ECG, the tech was either instructed by an ED physician to perform a second ECG to obtain a right-sided series or they had a standing protocol to do so in the event a patient presented with this specific type of infarction. WHAT THEY DID RIGHT: The tech correctly placed the precordial electrodes and attached the cables so that they are now monitoring leads V1R through V6R (a full rather than a partial right-sided series). This was done in an attempt to determine if there is any right ventricular (RV) involvement (esp. in leads V3R and V4R). WHAT THEY DID WRONG: The tech needlessly switched the right arm and left arm cables so that the overall ECG now superficially mimics a patient with mirror-image dextrocardia having an acute inferior infarction while having their ECG configured in a convention "standard" placement. In the ECG, lead II is really lead III and lead III is really lead II. Leads aVR and aVL are also transposed. Lead I is, or course, inverted. The tech probably knew that there are two primary occasions when you perform a right-sided series and they got confused. There was no reason for them to reverse the RA and LA cables.

Jason E. Roediger - Certified Cardiographic Technician (CCT)
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