ECG Lead Misplacement -Fool Me Once Shame on You, Fool Me Twice Shame on Me

Case Report

Austin Emerg Med. 2016; 2(4): 1025.

ECG Lead Misplacement -Fool Me Once Shame on You, Fool Me Twice Shame on Me

Grossi I1 and Lynch RM2*

¹Senior House Officer in Emergency Medicine, Midland Regional Hospital, Mullingar, Co. Westmeath, Ireland

²Consultant in Emergency Medicine, Midland Regional Hospital, Mullingar, Co. Westmeath, Ireland

*Corresponding author: Richard M Lynch, Consultant in Emergency Medicine, Midland Regional Hospital, Mullingar, Co. Westmeath, Ireland

Received: March 03, 2016; Accepted: April 18, 2016; Published: April 20, 2016

Abstract

ECG lead misplacement can dramatically alter the appearance of the ECG. If this is not detected significant and profound errors in treatment can ensue. We report the case of a 42 year old male who presented following a fall down a flight of stairs. An ECG was performed and this was compared with a previously recorded ECG which was filed in the patient’s hospital record. Two separate limb lead misplacements were present on this ECG even though classical features of both limb lead misplacements were present. Not only was this ECG filed in the in-patient records the ECG was not signed off by a senior doctor.

Highlights: ECG lead misplacements alter the ECG diagnosis in approximately 25% of cases.

Use of the “REVERSE mnemonic” has the potential to highlight incorrect lead placement.

A near-flat line in lead II is characteristic of right arm-right leg misplacement.

In RA-LA misplacement P-QRS-T complexes are negative in lead I and positive in a VR.

Keywords: ECG lead misplacement; “REVERSE” mnemonic; Right arm -right leg misplacement; Right arm- left arm

Introduction

The Electrocardiogram (ECG) is one of the most important and most frequently requested investigations in the management of the acutely unwell patient [1]. It is inexpensive, quick and easy to record and this record is easy to reproduce if appropriate attention to the placement of electrodes is given [2]. In spite of this lead misplacements do occur which, if not recognized, may have disastrous consequences with patients receiving the wrong treatment or not being treated at all based on the features of an incorrectly acquired ECG [3].

We describe a previously unreported case in which two separate limb lead misplacements occurred simultaneously on the same ECG even though the characteristic features of both were clearly evident. A review of the ECG appearances of both examples of misplacement is presented together with tips on how to recognize these lead misplacements.

Case Presentation

A 42 year old male, with a background history of epilepsy, presented to our Emergency Department (ED) after falling down a full flight of stairs. He stated that he felt like he was going to have a seizure while at the top of the stairs. The next thing that he remembered was waking up at the foot of the stairs. He complained of injuries to his head and neck.

On examination vital signs were within normal limits. Tenderness was elicited over the occiput and the upper cervical spine. A CT scan of his head and neck was performed, both of which were normal.

An ECG was performed to determine if his fall might have been due to an arrhythmia. This was normal (Figure 1). Due to the potential causes and consequences of the fall the in-patient records were retrieved to search for any relevant past medical conditions and also to compare his ECG with previously recorded ones. One of the ECGs in the in-patient records, which had been recorded one year earlier, revealed classical features of not one but two different types of ECG limb lead misplacement, namely right arm – right leg misplacement and right arm – left arm misplacement (Figure 2). Of note this abnormal ECG does not appear to have been “signed off” by a senior doctor. It was filed in the in-patient notes and even though previously recorded ECGs with no evidence of lead misplacement were available for comparison these two limb lead misplacements went undetected. It was not possible to identify who had missed the lead misplacements. It was never our intention to reprimand any member of staff as a result of these errors. We chose to educate all medical staff and nursing staff, regardless of status, on the appearance of limb lead misplacements. We hope that this intervention will help reduce the overall numbers of lead misplacements, and in particular those which heretofore have gone undetected.