Why is there ST Elevation in lead V2? Think Lead Placement.

 I was shown this ECG of a 40-something intoxicated male with altered mental status.  The provider was very worried about LAD occlusion.What do you think?There is ST Elevation in lead V2, but there is also an RSR ' wave which creates a kind of saddle ( " saddleback pattern " ).  This is rarely due to anterior MI.  There is also tachycardia, which unless a patient has cardiogenic shock, is also uncommonly due to ACS.  And, of course, without chest pain, the pretest probability is very low.RSR ' and saddleback can be due to leads being placed too high, but since the P-wave is upright in lead V2, I did not think that was the problem.I said it was unlikely to be ischemic.  I recommended IV fluids and to measure a troponin.  A cardiac POCUS would be useful to be certain there is good LV function.  One would expect it to be hyperdynamic.Then record another ECG after that.  And measure troponins.3 hours later I went to see if another ECG was recorded.  As I walked into the patient ' s room, this ECG was being printed out from the ECG machine:There is still an RSR ' and STE in V2.I looked at the lead placement.Leads V1 and V2 were far too high on the chest.I placed them correctly and instructed the tech to record again.Here is what came out:Correcting the lead placement resulted in a more normal ECGAll trops were negative.Learning Points:1. Pretest probability is crucial2. Saddleback (which is almost always lead V2) is ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs