Advertisement

A memorable cause of ST elevation

      To the Editor:
      A 46-year-old female with hypertension, presented to the hospital with syncope. She was found to have unprovoked submassive bilateral pulmonary embolism. Serum troponin was 0.61. Echocardiography revealed right ventricular dilatation and positive for McConnell's sign. She received catheter-directed thrombolysis.
      On the third day of admission, her symptoms improved and she was transferred to medical floor. Heparin was transitioned to rivaroxaban. She reported new left-sided substernal chest pain. On physical examination, her vital signs were all normal, but there was a small hematoma on her right groin. EKG (Fig. 1) revealed ST elevation in aVL and V6, with reciprocal changes in lead II, III, aVF.
      Fig. 1
      Fig. 1a. EKG demonstrated ST depression and T wave inversion in II, III, aVF. Positive QRS in V1. b. Lead V1 was switched with LL, V3 was switched with RL due to the port color looks alike. c. EKG with the corrected demonstrated T wave inversion in V1–V3.
      What is the diagnosis?

      Diagnosis: EKG leads misplacement

      Due to positive R wave in V1, EKG leads position was checked. Every leads were attached to the patient at the right positions but lead V1 and LL were misconnected at the machine because the color looks similar. (Fig. 1) EKG with the corrected leads revealed T wave inversion in anterior leads. (Fig. 1) Patient was found to have demand ischemia secondary to blood loss from abdominal wall hematoma after procedure. She was transfused and her symptom improved.
      EKG lead misplacement occurs 0.4% and 4% in outpatient clinic and intensive care unit, respectively [
      • Rudiger A.
      • Hellermann J.P.
      • Mukherjee R.
      • Follath F.
      • Turina J.
      Electrocardiographic artifacts due to electrode misplacement and their frequency in different clinical settings.
      . It can lead to misdiagnosis and unnecessary treatment for the patient. When suspicious of electrode misplacement, verifying all lead connections and obtaining another EKG is recommended.

      Conflict-of-interest disclosure

      The authors declare no competing financial interests.

      Reference

        • Rudiger A.
        • Hellermann J.P.
        • Mukherjee R.
        • Follath F.
        • Turina J.
        Electrocardiographic artifacts due to electrode misplacement and their frequency in different clinical settings.
        Am J Emerg Med. 2007; 25: 174-178