What can you tell me about this ECG strip?

Editorial Team / Admin · Oct 18, 2005

Hello,
I am still learning this, as is about to be readily apparent.
The patient was a post-CABGx4, the heart rate is 95. It is from lead II. I see that the rhythm looks regular, I see the inverted QRS (is that normal for some people?- I think my teacher said that?), the T seems big, and the leading edge of the P is higher than the ending (it dips down before the QRS, does that make sense?).
Can someone who knows what they are talking about tell me what they see & what it means, if anything?
I took a picture, let's see if I can get it attached.
Thanks for any feedback!

Hello, mitchsmom,:balloons:

Are you certain this is Lead II? The R wave is so small even for Lead II.

Lead II should be very positive. I would like to see a 12 lead on this pt.

The ST segment is elevated indicative of possible myocardial injury in the inferior wall.

The QRS being flipped is not normal. One cause for the flipped QRS could be lead reversal or something like dextrocardia.

mitchsmom · Oct 18, 2005

Hello, mitchsmom,:balloons:
Are you certain this is Lead II? The R wave is so small even for Lead II.
Lead II should be very positive. I would like to see a 12 lead on this pt.
The ST segment is elevated indicative of possible myocardial injury in the inferior wall.
The QRS being flipped is not normal. One cause for the flipped QRS could be lead reversal or something like dextrocardia.

I think it's lead II? - at the top of the strip (the part not in photo of course), it has "II" after the date, I thought that ID'd it as lead II???

Dextrocardia... heart on the wrong side? No, it's on the left side for sure.

Editorial Team / Admin · Oct 18, 2005

I'm just wondering if it is a lead reversal.....

mitchsmom · Oct 18, 2005

I'm just wondering if it is a lead reversal.....

What's that mean, and should the telemetry tech have noticed that?

Editorial Team / Admin · Oct 18, 2005

What's that mean, and should the telemetry tech have noticed that?

If the tech placed the leads, yes, she/he should have. But, if not, no. The leads can be reversed during placement and that can cause the deflected QRS. I would like to see a 12 lead to evaluate a better reading.

Tweety, BSN, RN · Oct 18, 2005

Some people do have QRS's that look like that. If you're sure it's not a lead reversal.

Considering they are post-CABG and may have had ischemic heart disease prior to the CABG the t-wave abnormality is not to surprising. How were his electrolytes, like potasium?

If I were charting I would say "Normal sinus rhythm with large t-wave" or something along those lines. The QRS might be a bit wide, so there might be a bundle branch block, but I would have to measure it.

Another trick is to look at a patients recent 12-lead EKG (all post CABG patients should have one) and compare.

mitchsmom · Oct 18, 2005

Some people do have QRS's that look like that. If you're sure it's not a lead reversal.
Considering they are post-CABG and may have had ischemic heart disease prior to the CABG the t-wave abnormality is not to surprising. How were his electrolytes, like potasium?
If I were charting I would say "Normal sinus rhythm with large t-wave" or something along those lines. The QRS might be a bit wide, so there might be a bundle branch block, but I would have to measure it.
Another trick is to look at a patients recent 12-lead EKG (all post CABG patients should have one) and compare.

I thought about the K+ but it was ok; all labs were WNL except:

WBC 11.8, RBC 3.53, HCT 34.0, BUN 19, Ca++ 7.9

If I've figured correctly, those are a little off but none too bad & potentially normal s/p CABG effects??

I figured the QRS at 0.08, maybe 0.10

My HE segment (Head-Exploding) would be 0.001 if I looked at a 12-lead.

Tweety, BSN, RN · Oct 18, 2005

Maybe you should post this in the cardiac nurses forum for more feedback. I'm not the expert and we don't want any HE going on. :)

Those labs look o.k. considering. I think this ecg strip looks o.k. If he had a real healthy heart to start with perhaps he wouldn't have needed a CABG, so it's probably reflective of his ischemia/agina, etc. prior.

Good luck!

rjflyn, ASN, RN · Oct 18, 2005

I have worked in the ER/ critical care-cardiac transport for a number of years and have seen many a pt with a lead II tracing such as this. Its very common in fact. The patient as yours did typically has significant heart disease. More often as well these patients have had an infarction/infarctions at some point in time. You have to remember dead muscle is going to conduct the electrical impulse differently hence the wide bizarre QRS in this case. As well you cant and should not diagnose based on a single monitoring lead, that is best left up to a 12, 16 or 20 lead EKG- yes we can and do collect extra leads.

RJ

VickyRN, MSN, DNP, RN · Oct 19, 2005

I'm certainly no ECG expert :imbar , but the QRS complexes to me look narrow (0.10)???

The ST segment is definitely elevated above 1 mm, indicative of acute myocardial infarction or Prinzmetal's Angina (severe coronary artery atherosclerotic disease), but one would need a 12-lead to accurately state this. If this were my patient, I would notify the primary STAT and ask for a 12-lead to investigate further.

Normally QRS complexes are upright in leads I, II, & AVF. Negative QRS complexes in lead II may suggest right axis deviation, but (again), a 12-lead ECG is necessary to accurately diagnose this. With right axis deviation, the QRS will be negative in lead I and positive in lead AVF.

Right axis deviation can signal right ventricular hypertrophy secondary to such medical conditions as COPD, severe pulmonary stenosis, and pulmonary hypertension. Is the patient a smoker with a long pack-year history?

T wave is tented - normally this signals hyperkalemia. However, the electrolytes have ruled this out. The onset of infarction can also cause the T waves to become tall and narrow.

Hypocalcemia can prolong the QT interval, placing the client at risk for R-on-T phenomenon and sudden cardiac death (from pulseless v-tach or v-fib).

So, in summary, a 12-lead ECG is necessary to accurately assess this patient's situation. Very interesting discussion. Thanks, mitchsmom :)

papawjohn · Oct 19, 2005

Hey M-Mom

This is a rhythm-strip, right? From the tele monitor? The usual 'lead 2' is accepted but is really what the tech or nurse who put the monitor 'dots' on gave you? And this is not from a 12lead EKG done by a trained tech or nurse? Yes?

I've spent almost 1/2 my (long) life watching monitors and have achieved some modest skills at 12lead ekgs. There is a huge difference between the two. The monitoring is to detect ectopics, to diagnose rhythms, etc. Simple monitoring does not analyse heart disease--only rhythms. This is obviously Sinus Rhythm.

Unless this is the lead II of a 12lead ekg, you cannot diagnose heart disease from it.

If it IS (which I doubt) the lead II of a 12 lead ekg, then the STSegment elevation is diagnostic of severe ischemia.

But please---very important---don't confuse the two.

Get back on the thread and give us the whole 12 lead ekg. We'd appreciate it.

Papaw John