BMJ Case Reports 2017; doi:10.1136/bcr-2017-221429
  • Learning from errors

Pathological ECG that seemed normal following electrode misplacement

  1. Jean-Pierre Tourtier1
  1. 1Paris Fire Brigade Department, Prehospital Emergency Medical Department, Paris, France
  2. 2Sudden Death ExpertiseCenter, INSERM U.970, Paris, France, Paris, France, France
  1. Correspondence to Dr Daniel Jost, daniel.jost{at}
  • Accepted 20 November 2017
  • Published 5 December 2017


We report the case of a 57-year-old woman found at home who received an ECG after having recovered from a seizure, without any clinical cardiac anomaly. The ECG revealed an elevation of the ST segment from the V1 to V5 leads and negative T waves from V1 to V5 leads. At her hospital admission, the emergency care unit (ECU) nurse performed another ECG. It no longer showed any repolarisation anomaly. However, the ECU nurse had put the precordial electrodes 3 cm too low, probably due to the patient’s voluminous breasts. In the end, the pathological trace reappeared after we returned the electrodes to their initial positions. Malpositioning of the electrodes caused a seemingly normal ECG result with life-threatening consequences.


  • Contributors CD prehospital management. DJ and CD supervised data collection. HL, CD and DJ J-PT drafted the manuscript. All authors take responsibility for the paper as a whole.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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