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ECG Interpretation Confounders

Article  in  American Journal of Critical Care · January 2013

DOI: 10.4037/ajcc2013719 · Source: PubMed

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Mary G. Carey Salah S Al-Zaiti

University of Rochester University of Pittsburgh
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Teri M Kozik Michele M Pelter

St Joseph's Medical Center Stockton University of Nevada, Reno
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ECG Puzzler
A regular feature of the American Journal of Critical Care, the ECG Puzzler addresses electrocardiogram (ECG) interpretation for clinical practice.
To send an eLetter or to contribute to an online discussion about this article, visit www.ajcconline.org and click “Respond to This
Article” on either the full-text or PDF view of the article. We welcome letters regarding this feature.

ECG INTERPRETATION CONFOUNDERS

By Mary G. Carey, RN, CNS, PhD, Salah S. Al-Zaiti, RN, NP, Teri M. Kozik, RN, CNS, PhD, and
Michele M. Pelter, RN, PhD

Scenario: A 45-year-old female executive arrived medical or surgical history, takes no medication, has a
at the emergency room with complaints of substernal normal body mass index, and exercises regularly. Below
chest pressure and shortness of breath. She has no prior is her 12-lead ECG obtained in the emergency room.

I ↓V1 ↓V4
↓aVR

II ↓ V2 ↓V5
↓aVL

III
↓aVF ↓ V3 ↓V6

Interpretation Questions:
1. Is the ECG properly calibrated (10 mm) and are leads properly placed? ❑ Yes ❑ No ❑ NA
If no, interpret cautiously.
2. Is this a sinus rhythm (one P wave preceding every QRS complex)? ❑ Yes ❑ No ❑ NA
If no, check for number of P waves in relation to QRS complexes.
3. Is the heart rate (R-R interval) normal (60-100/min)? ❑ Yes ❑ No ❑ NA
If no, check for supra-ventricular or ventricular arrhythmias.
4. Is the QRS complex narrow (duration < 110 milliseconds [ms] in V1)? ❑ Yes ❑ No ❑ NA
If no, check for bundle branch blocks (BBBs), pacing, or ventricular arrhythmia.
5. Is the ST segment deviated (> 2 mm in V2-V3, or > 1 mm in other leads)? ❑ Yes ❑ No ❑ NA
If yes, check for similar deviations in contiguous cardiac territories.
6. Is the T wave inverted in relation to the QRS (> 0.5 mV)? ❑ Yes ❑ No ❑ NA
If yes, check for ST deviation or conduction abnormalities.
7. Is the QT interval lengthened (> 450 ms [women] or > 470 ms [men])? ❑ Yes ❑ No ❑ NA
If yes, check for ventricular arrhythmias or left ventricular hypertrophy.
8. Is R or S wave amplitude enlarged (S wave V1 + R wave V5 > 35 mm)? ❑ Yes ❑ No ❑ NA
If yes, check for axis deviation or other chamber hypertrophy criteria.

Mary G. Carey is associate director for clinical nursing research, Strong Memorial Hospital, Rochester, New York. Salah S.
Al-Zaiti is a doctoral student at the School of Nursing at the State University of New York at Buffalo Teri Kozik is supervisor
of cardiac research at St. Joseph’s Medical Center, Stockton, California. Michele M. Pelter is an assistant professor at the
Orvis School of Nursing, University of Nevada, Reno.

©2013 American Association of Critical-Care Nurses, doi: http://dx.doi.org/10.4037/ajcc2013719

www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2013, Volume 22, No. 1 77

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 I ↓aVR ↓ V1 ↓V 4

II
↓aVL ↓ V2 ↓V 5

III
↓aVF ↓ V3 ↓ V6

Answers:

1. Yes, the ECG is properly calibrated. There is limb lead reversal of the left arm and right arm lead wire. Thus, the
limb leads must be ignored and only the precordial leads can be analyzed.
2. Yes, the rhythm is sinus.
3. Yes, heart rate is regular at 99/min.
4. Yes, the QRS duration is narrow.
5. No, there is no diagnostic ST segment deviation.
6. Yes, there is T wave inversion in the precordial leads V5 and V6.
7. No, the QT interval is not lengthened.
8. No, there are no electrocardiographic signs of left ventricular hypertrophy.

Interpretation repeat the ECG. Unfortunately, this error was not

The ECG shows normal sinus rhythm at
99/min plus lateral ST changes (T wave inversion
in V5 and V6). Although not diagnostic, it may
suggest myocardial ischemia. Limb lead reversal
prevents interpretation of the limb leads.
Rationale
Lead reversal is frequent and has become
more common as nonexperienced personnel
replace trained ECG technicians.
This type of lead reversal affects all of the
limb leads but lead I can be used to identify this
error by checking for the following: (1) inverted
QRS complex; (2) a striking Q wave; (3) inverted
T wave; and (4) a notable inverted P wave. How-
ever, the precordial leads should exhibit normal R
wave progression, as seen in this scenario. If a pre-
vious ECG is available, these changes can be easily
identified. Limb lead reversal is the most common
frontal lead error and the only correction is to
detected in this patient prior to discharge so the ECG
was not repeated.
Nursing Actions
The patient’s age, sex and physical fitness place her
at low or intermediate risk for acute coronary syndrome
(ACS). However, ACS accounts for almost 15 percent of
patients who seek treatment in the emergency department;
thus an evaluation that includes an initial history, phys-
ical exam, ECG, and serum biomarkers is warranted.
Special consideration should be given to the fact
that females can have atypical presentation and that
subtle lateral wall changes may warrant further investi-
gation. Also, the patient reports being an executive,
which may suggest that she is having a cardiac event
caused by chronic anxiety related to a high-demand
career. Given this patient’s symptoms, elevated heart
rate and the T-wave inversion seen in leads V5 and V6,
a repeat ECG should be obtained immediately to
assess the limb leads for possible ischemia.

78 AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2013, Volume 22, No. 1 www.ajcconline.org

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ECG Interpretation Confounders
Mary G. Carey, Salah S. Al-Zaiti, Teri M. Kozik and Michele M. Pelter
Am J Crit Care 2013;22:77-78 doi: 10.4037/ajcc2013719
© 2013 American Association of Critical-Care Nurses
Published online http://www.ajcconline.org

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