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how to diagnose when there is reversal of limb leads. description with ECGS
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ECG LIMB LEAD REVERSAL
DR.PRAVEEN NAGULAI yr pg in cardiology
Ogh,hyd
Introduction
Accidental misplacement of the limb lead
electrodes is a common cause of ECG
abnormality and may simulate pathology such
as ectopic atrial rhythm, chamber enlargement
or myocardial ischaemia and infarction.
When the limb electrodes (LA, RA, LL) are
exchanged without disturbing the neutral
electrode (RL/N), Einthoven’s triangle is
“flipped” 180 or rotated, resulting in leads
that switch positions, become inverted or
remain unchanged (depending on their
initial position and vector).
Exchanging one of the limb electrodes with
the neutral electrode (RL/N) disrupts
Einthoven’s triangle and distorts the zero
signal received from Wilson’s central terminal,
altering the appearance of both limb and
precordial leads.
Limb leads may be grossly affected, taking on
the appearance of other leads or being reduced
to a flat line.
DEFINITIONS
ELECTRODES
LA – left arm RA – right arm LL -- left leg RL/N- right leg (neutral electrode)
LEADS
Bipolar leads: I, II, III Augmented unipolar leads: aVL, aVF, aVR Wilson’s central terminus (WCT): the
‘zero’ lead, produced by averaging signals from the limb electrodes.
EINTHOVEN’S TRIANGLE
Relationship between the limb leads and electrodes is described by Einthoven’s triangle.
Each lead has a specific quantity and direction (vector) produced by adding or subtracting voltages from the recording electrodes.
BIPOLAR LEADS
Lead I is the voltage difference between
the LA and RA electrodes (LA – RA),
directed towards LA at 0.
Lead II is the voltage difference between
the LL and RA electrodes (LL – RA),
directed towards LL at +60.
Lead III is the voltage difference between
the LL and LA electrodes (LL – LA),
directed towards LL at +120 .
Augmented Unipolar leads
Lead aVL is directed towards the LA
electrode (-30 ) calculated as follows:
aVL = LA – (RA+LL)/2.
Lead aVF is directed towards the LL
electrode (+90 ), calculated as follows:
aVF = LL – (LA + RA)/2.
Lead aVR is directed towards the RA
electrode (-150 ), calculated as follows:
aVR = RA – (LA + LL)/2.
WILSON’S CENTRAL TERMINUS
This directionless “zero lead” lead is
calculated as the average input from
the three limb leads:
WCT = 1/3 (RA + LA + LL).
An understanding of Einthoven’s triangle and the mathematical derivations of each lead will help us in understanding the ECG patterns produced by each type of limb lead reversal.
LA/RA reversal
With reversal of the LA and RA electrodes, Einthoven’s triangle flips 180 horizontally around an axis formed by lead aVF.
This has the following effects on the ECG:Lead I becomes inverted.
Leads II and III switch places.Leads aVL and aVR switch places.
Lead aVF remains unchanged.
NORMAL When LA, RA changed
BASELINE ECG
LA/RA reversal
QUICK GUIDE to SPOTTING LA/RA REVERSAL
Lead I is completely inverted (P wave, QRS complex and T wave).
Lead aVR often becomes positive. There may be marked right
axis deviation.
LA/RA reversal may simulate dextrocardia.
However, in contrast to dextrocardia there is normal R wave progression in the precordial leads.
LA/RA reversal simulating dextrocardia
LA/RA reversal reversed
LA/LL reversal
With reversal of the LA and LL
electrodes, Einthoven’s triangle rotates 180
vertically around an axis formed by aVR.
This has the following effects on the ECG: Lead III becomes inverted. Leads I and II switch places. Leads aVL and aVF switch places. Lead aVR remains unchanged.
Baseline ECG
LA-LL reversal
Quick guide to spotting LA/LL reversal
Lead III is completely inverted (P
wave, QRS complex and T wave)
The P-wave is unexpectedly larger in lead I
than lead II (it is usually the other way
around).
RA/LL reversal
With reversal of the RA and LL
electrodes,
Einthoven’s triangle rotates 180
vertically around an axis formed by aVL.
This has the following effects on the ECG: Lead II becomes inverted. Leads I and III become inverted and
switch places. Leads aVR and aVF switch places. Lead aVL is unchanged.
Baseline ECG
RA/LL reversal
Quick guide to spotting RA/LL reversal
Leads I, II, III and aVF are all completely
inverted
(P wave, QRS complex
and T wave).
Lead aVR is upright.
RA/RL(N) reversal
With reversal of the RA and RL(N) electrodes,
Einthoven’s triangle collapses to very thin “slice”
with the LA electrode at its apex.
The RA and LL electrodes now record almost
identical voltages, making the difference between
them negligible (i.e, lead II = zero).
Lead aVL runs within this thin slice, facing approx.
opposite to lead III.
Displacement of the neutral electrode renders leads
aVR and aVF mathematically identical, such that
they appear exactly alike (but different to the
baseline ECG).
RA/RL(N) lead reversal has the following ECG features:
Lead I becomes an inverted lead III. Lead II records a flat line (zero
potential). Lead III is unchanged. Lead aVL approximates an inverted
lead III. Leads aVR and aVF become identical.
As the neutral electrode has been moved,
the precordial voltages may also be distorted.
Baseline ECG
RA/RL(N) reversal
Quick guide to spotting RA/RL(N) reversal
Lead II is a flat line.
LA/RL(N) reversal
With reversal of the LA and RL(N) electrodes,
Einthoven’s triangle collapses to very thin “slice” with
the RA electrode at its apex.
The LA and LL electrodes now record almost
identical voltages, making the difference between
them negligible (i.e. lead III = zero).
Lead aVR runs within this thin slice, facing approx.
opposite to lead II.
The displacement of the neutral electrode renders
leads aVL and aVF mathematically identical, such
that they appear exactly alike (but different to the
baseline ECG).
LA/RL(N) lead reversal has the following ECG features:
Lead I becomes identical to lead II. Lead II is unchanged. Lead III records a flat line (zero
potential). Lead aVR approximates to an inverted
lead II. Leads aVL and aVF become identical.
As the neutral electrode has been moved, the precordial voltages may also be distorted.
Baseline ECG
LA/RL(N) reversal
Quick guide to spotting LA/RL(N) reversal
Lead III is a flat line
Bilateral Arm-Leg Reversal (LA-LL plus RA-RL)
If the electrodes on each arm are swopped with their corresponding leg electrode (LA with LL, RA with RL), Einthoven’s triangle collapses to a very thin slice with the LL electrode at its apex.
The RA and LA electrodes (now sitting on adjacent feet) record almost identical voltages, which makes the difference between them negligible (i.e. lead I = zero).
Leads II, III and aVF all become identical (equivalent to inverted lead III), as they are all now measuring the voltage difference between the left arm and the legs.
The displacement of the neutral electrode renders leads aVL and aVR mathematically identical, such that they appear exactly alike (but different to the baseline ECG).
Bilateral arm-leg reversal has the following ECG features:
Lead I records a flat line (zero potential). Lead II approximates an inverted lead III. Lead III is inverted. aVR and aVL become identical. aVF looks like negative lead III.
As the neutral electrode has been moved, the precordial voltages may also be distorted.
Baseline ECG
Bilateral arm-leg reversal
Quick Guide To Spotting Bilateral Arm-Leg Reversal
Lead I is a flat line.
LL/RL(N) reversal
With reversal of the lower limb electrodes,
Einthoven’s triangle is preserved as the
electrical signals from each leg are
virtually identical.
The ECG is therefore unchanged.
Baseline ECG
LL/RL(N) reversal
How to spot LL/RL(N) reversal
You won’t!
But don’t worry, it won’t make any difference to your ECG interpretation.