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Wednesday, 12 March 2014

#ECGclass - Spring4-vii - When ECGs go bad!

Welcome to another weekly case on ECGclass. :)
If you are new to either @ECGclass, #ECGclass, or this blog - please click  here to find out what it's all about! 

ECG class is delighted to welcome our second guest speaker of the term!

A big welcome to Simon Ross Deveau.

Simon can be found on Twitter @sydeveau or via his ECG blog:  Bits and Pieces from an ED Nurse
As an ED nurse, Simon has come across a variety of ECG problems in the ED.
Problems range from ED staff doing them wrong, ambulance crews querying ischaemia/ST deviation, and people being referred in with abnormal ECGs, who go on to have normal ECGs when electrodes and leads are positioned correctly. 

So this weeks ECG class looks at a case of mistaken identity.
What happens when ECGs are done wrong?

Thank you Simon! :)
Here goes, and have fun…..…


#ECGclass Spring4

Q1.      What is the correct electrode position of the precordial leads?


Correct precordial lead positioning:
V1    L sternal border, 4th intercostal space. 
V2    R sternal border, 4th intercostal space 
V4    Midclavicular line, 5th intercostal space. 
V5    Anterioraxillary line
V6    Midaxillary line
V3    Midway between V2 & 4.


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Q2.     What technical error does the ECG below show?



The ECG above shows leads RA & LA to be reversed. 

Lead I is –ve and aVR is +ve = general R direction of cardiac impulse. 

The differential diagnosis here would be right sided heart (dextrocardia/dextroposition).


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Q3.     How about this one?



This ECG shows reversal of V1-V6. 
Note the RS progression in reverse.


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Q4.    Are we worried about this ECG?



Note that lead I shows normal sinus rhythm.   
Remember to treat the pt not the ECG!  

This is VT artefact from movement.



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Q5.    At least this one doesn’t need defibrillating, but it there correct lead placement?


Note the amplitude of lead I > II . This is always suspicious. 
The P wave in Lead III has a small +ve  deflection at the end. This is Abdollah Sign 
(The amplitude of the P wave in lead I greater than in lead  II and/or  a P wave terminal positive component in lead III).
Abdhollahs sign = LA & LL reversal.




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Q6.    What about this ECG?





Image thanks to ECGlibrary.com






Normal sinus rhythm! 
All the above ECGs could well have come from the same patient so remember to treat the patient, not their ECG! 
If ECG  looks wrong, then redo - If in doubt throw it out!



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Q7.    And Finally…...What general rules could you use to check for correct electrode   placement?






Please use the Hashtag #ECGclass if joining in on Twitter!

If you want to ask the patient any questions, or request any further investigations this can  be done by the hashtag during the course of this evening. 

Alternatively, if referring to this blog at a later date, please leave comments below.



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