Peds EKG question

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BeansCO

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Hey guys,

I am a EMT in Colorado with my EKG cert. I work in an ER and I ran into a scenario I never learned about or have encountered yet. I wish I had strips to show. I apologize if this is something I should 100% know how to do.

I ran a EKG on a 16 month old in respiratory distress. Our protocol is that kiddos under 12 get V3 on the right side. Rhythm-wise all looked good except in V3 I had a wave that occurred relatively regularly. It made the picture look like crap so I troubleshot the issue and I realized that the waves occurred when the patients chest wall rose during inhalation/exhalation. I attribute the crappy picture to that.

Is there a reason I am getting the muscle movements due to operator error?
Why is it only in V3?
What could I do differently in the future?

Thanks,

Beans
 
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Here's the report. He was fussy the whole time too. If you have any suggestions or you see any other errors let me know! I'm always trying to improve.
 
It does look like motion artifact. Bit odd to see it so dramatically in just one lead. Maybe that wire was particularly floppy or dangly.
 
Just the normal suggestions here. (1) Check your electrodes. aren't expired or dried out, (2) How is your skin prep? And (3) Check your limb leads. There's a bit of baseline wander in the ECG. Remember that they're used to form the virtual negative electrode in the precordial leads. Probably one of your first actions should be to change the V3 electrode.
 
The electrodes were still good. Brand new pack well before expiration. I didn't really focus on skin prep. The kiddo is only 16 months old. He was not excessively diaphoretic.

I should have personally double checked the limb leads and v3. I had the RT take a quick look to get a second set of eyes and asked her to evaluate the v3 lead. She said it looked fine. I asked her to move it just just a bit and it helped reduce the artifact in the other leads a little bit. Should have done a true evaluation from machine to patches.

Oh well.
 
There could be issues with the cable for V3 as well. I find people often grab the LP15 chest cable and pull all six leads off at once, which irritates me to no end. It tends to upset patients, and results in damage to the cables that results in early failure.

Just a couple of other things to add:

Note with the ECG that you have a rightward axis, and large precordial R waves. These are normal findings in young children, as their left ventricles are smaller relative to their RV. You also have T wave inversion in V1, V2, and V3R. These are usually persistent juvenile T waves. This is commonly misinterpreted as an ischemic change by people who aren't familiar with pediatric ECGs.
 
Nothing wrong with the EKG. Look at your long Lead II strip - that same fluctuation is there as well. It's just respiratory variation (which you already noted) - totally normal.
 
BeansCO said:
Why is it only in V3?
Click to expand...

The movement of a precordial lead (V1-6) to the right side gives an extra view but from the right side, to look at the right ventricle, a standard 12-Lead looks primarily at the left ventricle.

I'm not sure why you are told V3 (which should me annually labeled V3R on the print out since the machine labled it V3). I was always instructed to move V4 to the right side.

I'm also not sure why your policy states to do this for pediatrics, generally this is used to check for right sided heart failure in cardiac patients.
 
Yes I agree, with the previous poster. If I was to do an inferior 12 lead, I would move lead 4 to the right side and not lead 3. This is usually done to look at the right ventricle.
 
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