ST Elevation in aVL with reciprocal ST Depression in inferior leads and DIffuse ST depression

An elderly male had volume depletion and anemia, and complained of chest pain.We recorded this ECG:Q-waves and ST Elevation in I and aVLST Depression in inferior (reciprocal to aVL) and precordial leads.  Is it posterolateral OMI?What do you think?Notice that not only are there Q-waves in I and aVL, they are QS-waves (there are no R-waves).However, there are very well-formed R-waves in the other " lateral " leads, V5 and V6.These 4 lateral leads do notalways look identical, as V5 and V6 are more inferior that I and aVL, but they should never look this differentEXCEPT if you are recording aright sided ECG in someone withDextrocardia.Notice also that, in spite of STD in V5, there is STD in aVR. These leads are effectively opposite each other and should be reciprocal to each other.So this is lead reversal.  The computer did NOT see this.Here is what it looked like after we placed the leads correctly:This is also after blood and fluid resuscitation, so that there is less ischemia evident.This is supply/demand subendocardial ischemia, and it finally resolved with full resuscitation.Learning Points:1. R-waves in I/aVL should not be opposite to V5, V62. STD in V5 should be accompanied by STE in aVRThese points should be major clues to lead reversal.===================================MY Comment by KEN GRAUER, MD (2/11/2020):===================================ECG Courses and textbooks often pay little attention to recognition of lead misplacement. As a re...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs