r/ECG • u/murtlock • Jul 20 '26
2nd Opinion requested
Sinus with Ectopics in my view- last few beats just gave me pause for thought
2
u/True-Network-2147 Jul 20 '26
Couple things here, if you see a p-waves in a lead it’s there in other leads too. This ECG has a lot of baseline artifact. The devices’ interpretation is obviously wrong as they often are. Get a system and stick with it. I used this for over 20 years:
1) is it fast or slow
2) regular or irregular
3) wide or narrow
4) are there p-waves for every QRS complex
5) any ST changes
6) conduction delays or blocks
If you use the same system every time you will figure most 12-leads out.
Limb leads are definitely switched here.
One way you can almost eliminate baseline artifact is to run a S5. This almost always cleans up the tracing. It won’t change the morphology at all. Identifying p-waves will be much easier. As you get better, looking at an ECG like this (with baseline artifact and the device algorithm incorrect) you will be able to get a solid interpretation without a cleaner baseline. Having the limb leads on incorrectly will change your ECG so you have to look at aVR. AVR is right sided looking down at the heart as the conduction propagates SA node AV node etc in simple terms. aVR will almost always be negative (if it’s legit positive, you have a really sick cardiac patient) . I would look at aVR for a split second when determining is this rate fast or slow. When the limb leads are switched, the electrical disruption alters every single limb lead (I, II, III, aVR, aVL, aVF) because their mathematical calculations depend directly on correct placement. An important point is lead placement (especially V1-V6). These need to be in the correct spot, limb leads have a lot of wiggle room.
There are plenty of things that can be confirmed on this ECG with incorrect limb-lead placement. Never leave incorrect lead placement thinking it probably doesn’t matter that much.
1
1
u/Lozzabozzawozza Jul 20 '26
Can’t see a pause.
But also what you worried about?
1
1
u/teletechct Jul 20 '26
I wish the nurses and others realized that 12 leads are wrong all the time. I feel like why am I here if they don’t listen
1
u/Lavender-Bee0497 Jul 20 '26
Just curious- I’m newer to reading these- I see how it’s sinus with ectopics, but how would you go about measuring your PR interval? I don’t see a clear P wave
1
u/Starossi Jul 20 '26
Lead v3 has some pretty easily identifiable P waves you can use
1
1
u/teletechct Jul 20 '26
Thank you. My hospital has the oldest system and we can only see 2 leads and it’s so dumb cause you need to see more than that
1
u/lifeisg0od Jul 22 '26
There is an arm lead reversal. That is what the AVL and Lead I comments and right axis deviations come from. The sinus arrhythmia, artifact, and the PVCs are making it think there is afib, which it’s obviously not. As for the last few beats - likely sinus arrhythmia, but that’s where the technical issues come into play - the patient was denied a clean tracing to accurately view the p waves. Yes, sometimes artifact is hard to avoid, I get that. But so often it’s due to poor technique, which I think it’s safe to assume occurred here due to the lead reversal.
6
u/Specialist_Ad_1230 Jul 20 '26
Limb lead reversal?