Bizarre (Hyperacute??) T-waves

Thanks to one our great HCMC nurses, Ryan Burch.  He figured this one out.A dialysis patient presented with dyspnea.  He was a bit fluid overloaded and not hyperkalemic. This ECG was recorded:This was sent to me in a text that woke me from sleep, but not simultaneous with patient care.Truly bizarre T-waves in I, aVL, III, aVF, aVRLead II is unremarkable, and leads V3-V6 are also slightly bizarre.What do you think?My answer, as I looked with bleary eyes at my phone: " I have to say I ' ve never seen this one before. "Later, I looked into the chart and found an ECG from a few days before:I texted back:" Those T-waves were gone 5 minutes later.  Artifact! "Ryan Burch, RN, was the nurse caring for the patient, later sent me the same ECG, stating the following:" This ECG had people stumped and concerned but I read an article inwww.ecgmedicaltraining.com (see below) about an artifact a few weeks prior which I thought looked similar and the suggestion was that a lead had been placed over an artery.  I switched lead placement and this ECG was recorded 5 minutes later: "He found that the left arm electrode had been placed near the patient ' s left arm dialysis fistula, which was pulsating with a palpable thrill.This resulted in the following:Wandering Artifact onlyExplanationAll leads are derived from 3 bipolar electrodes and one unipolar electrode.Leads I, II, and III depend on bipolar leads voltage differences:--Lead Iuses the right and left arm--Lead II use...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs