Inadvertent interchange of electrocardiogram limb lead connections: analysis of predicted consequences part II: double interconnection errors.

Limb lead connection errors are known to be very common in clinical practice. The consequences of all possible single limb lead interconnection errors were analyzed in an earlier publication (J Electrocardiology 2008;41:84-90). With a single limb lead interconnection error, 6 combinations of limb lead connections are possible. Two of these combinations give rise to records in which the limb lead morphology is uninterpretable. Such records show a "flat line" in lead II or III. Three of the errors give rise to records that are fully interpretable once the specific interconnection error has been identified (although one of the errors cannot reliably be recognized in the absence of a previous record for comparison). One of the errors produces no change in the electrocardiogram recording. In all cases, the precordial leads are interpretable, although there are very minor changes in the voltages. This communication predicts the changes in limb lead appearances consequent upon all possible double limb lead interchanges and illustrates these with records electively taken with such double interconnection errors. There are only 3 possible double limb lead interconnection errors. In 2 of the possible combinations, interpretation of the limb leads is impossible, and each of these errors gives rise to a flat line in lead I. In the third combination, the record is fully interpretable once the abnormality has been identified. In all 3 types, the precordial leads are interpretable, although there are very minor changes in the voltages.