Common ECG Lead Placement Errors. Part I: Limb lead Reversals
Keywords:Cardiology,, Electrocardiography, Medical Errors, Limb Lead Reversal, Medical Education
Background: Electrocardiography is a very useful diagnostic tool. However, errors in placement of ECG leads can create artifacts, mimic pathologies, and hinder proper ECG interpretation. This is the second of a two-part series discussing how to recognize and avoid these errors.
Methods: 12-lead ECGs were recorded in a single male healthy subject in his mid 20s. Various precordial lead misplacements were compared to ECG recordings from correct lead placement.
Results: Precordial misplacements caused classical changes in ECG patterns. Techniques of differentiating these ECG patterns from true pathological findings were described.
Conclusion: As in Part I of this series, recognition and interpretation of common ECG placement errors is critical in providing optimal patient care.
2. Mason JW, Hancock EW, Gettes LS, et al. Recommendations for the stan¬dardization and interpretation of the electrocardiogram: Part II: Electrocar¬diography diagnostic statement list a scientific statement from the American heart association electrocardiography and arrhythmias committee, council on clinical cardiology; the American college of cardiology foundation; and the heart rhythm society endorsed by the international society for computerized electrocardiology. J Am Coll Cardiol. 2007 Mar 13;49(10):1128-35.
3. Kligfield P. Gettes LS. Bailey JJ, et al. American Heart Association Elec¬trocardiography and Arrhythmias Committee,Council on Clinical Cardiology. American College of Cardiology Foundation.Heart Rhythm Society. Recom¬mendations for the standardization and interpretation of the electrocardio¬gram: Part I: The electrocardiogram and its technology a scientific statement from the american heart association electrocardiography and arrhythmias committee, council on clinical cardiology; the american college of cardio¬logy foundation; and the heart rhythm society endorsed by the internatio¬nal society for computerized electrocardiology. J Am Coll Cardiol. 2007 Mar 13;49(10):1109-27.
4. Rajaganeshan R, Ludlam CL, Francis DP, Parasramka SV, Sutton R. Accuracy in ECG lead placement among technicians, nurses, general physicians and cardiologists. Int J Clin Pract. 2008 Jan;62(1):65-70.
5. Sejersten M, Pahlm O, Pettersson J, et al. Comparison of EASI-derived 12-lead electrocardiograms versus paramedic-acquired 12-lead electrocardio¬grams using mason-likar limb lead configuration in patients with chest pain. J Electrocardiol. 2006 Jan;39(1):13-21.
6. Hoffman I. Einthoven's left foot: A plea for disciplined electrode place¬ment. J Electrocardiol. 2008 May-Jun;41(3):205-6.
7. Baranchuk A, Shaw C, Alanazi H, et al. Electrocardiography pitfalls and artifacts: The 10 commandments. Crit Care Nurse. 2009 Feb;29(1):67-73.
8. Koppikar S, Shaw C, Baranchunk A. ECG quiz: A tale of an abnormal ECG. J Electrocardiol. 2014 Jan-Feb;47(1):123-5.
9. Rudiger A, Hellermann JP, Mukherjee R, Follath F, Turina J. Electrocardiogra¬phic artifacts due to electrode misplacement and their frequency in different clinical settings. Am J Emerg Med. 2007 Feb;25(2):174-8.
10. Batchvarov VN, Malik M, Camm AJ. Incorrect electrode cable connection
during electrocardiographic recording. Europace. 2007 Nov;9(11):1081-90.
11. Knight BP, Pelosi F, Michaud GF, Strickberger SA, Morady F. Clinical conse¬quences of electrocardiographic artifact mimicking ventricular tachycardia. N Engl J Med. 1999 1000 Oct 21;341(17):1270-4.
12. Harrigan R, Chan T, Brady W. Diagnosis: Limb electrode reversal. Emergen¬cy Medicine News. 2004 Jun;26(6):18-20.
13. Garcia-Niebla J, Llontop-Garcia P, Valle-Racero JI, Serra-Autonell G, Batchva¬rov VN, de Luna AB. Technical mistakes during the acquisition of the electro-cardiogram. Annals of Noninvasive Electrocardiology. 2009 Oct;14(4):389-403.
14. Report of committee on electrocardiography, american heart association. Recommendations for standardization of leads and of specifications for ins-truments in electrocardiography and vectorcardiography. Circulation. 1967 Mar;35(3):583-602.
15. Drew BJ. Pitfalls and artifacts in electrocardiography. Cardiol Clin. 2006 vii; Aug;24(3):309-15.
16. Peberdy MA, Ornato JP. Recognition of electrocardiographic lead mispla¬cements. Am J Emerg Med. 1993 Jul;11(4):403-5.
17. Abdollah H, Milliken JA. Recognition of electrocardiographic left arm/left leg lead reversal. Am J Cardiol. 1997 Nov 1;80(9):1247-9.
18. Ho KK, Ho SK. Use of the sinus P wave in diagnosing electrocardiographic limb lead misplacement not involving the right leg (ground) lead. J Electro¬cardiol. 2001 Apr;34(2):161-71.
19. Eisenberg MJ, de Romeral LM, Heidenreich PA, Schiller NB, Evans GT Jr. The diagnosis of pericardial effusion and cardiac tamponade by 12-lead ECG. A technology assessment. Chest. 1996 Aug;110(2):318-24.
20. de Voogt WG, van Mechelen R, Scheffer M, van Miltenburg van Zijl AJ, Elhendy AA. Electrocardiographic characteristics in low atrial septum pacing. J Electrocardiol. 2005 Apr;38(2):166-70.
21. Hoffman I. A flatline lead I results from bilateral arm-to-leg electrode exchange. J Electrocardiol. 2008 Sep-Oct;41(5):388-90.
22. Srikureja W, Darbar D, Reeder GS. Tremor-induced ECG artifact mimicking ventricular tachycardia. Circulation. 2000 Sep 12;102(11):1337-8.
23. Knight BP, Pelosi F, Michaud GF, Strickberger SA, Morady F. Physician inter¬pretation of electrocardiographic artifact that mimics ventricular tachycardia. Am J Med. 2001 Apr 1;110(5):335-8.
24. Wieters JS, Carlin JP, Morris A. Case report: An electrocardiogram of spon¬taneous pneumothorax mimicking arm lead reversal. J Emerg Med. 2014 May;46(5):620-3.
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