ECG Lead Misplacement -Fool Me Once Shame on You, Fool Me Twice Shame on Me

ECG lead misplacement can dramatically alter the appearance of the ECG. If this is not detected significant and profound errors in treatment can ensue. We report the case of a 42 year old male who presented following a fall down a flight of stairs. An ECG was performed and this was compared with a previously recorded ECG which was filed in the patient's hospital record. Two separate limb lead misplacements were present on this ECG even though classical features of both limb lead misplacements were present. Not only was this ECG filed in the in-patient records the ECG was not signed off by a senior doctor. Highlights: ECG lead misplacements alter the ECG diagnosis in approximately 25% of cases. Use of the “REVERSE mnemonic” has the potential to highlight incorrect lead placement. A near-flat line in lead II is characteristic of right arm-right leg misplacement. In RA-LA misplacement P-QRS-T complexes are negative in lead I and positive in a VR.