A 9 yo girl with collapse

A 9 yo girl is brought into the emergency department, following an episode of syncope. She has a current viral illness and looks miserable. She was walking into the Emergency Department with her mother, when she collapsed. She recovered quickly with no post-ictal component but has no memory of the event, although the event was preceded by ‘dizziness’ and diaphoresis.  Her past medical history is ADHD, for which she is on no medication.
You review her in the triage room as the department is filled to capacity. The vitals are all normal but the child looks tired and has some coryza symptoms. You ask the resident to get the rest of the story and show you an ECG.
The resident brings you the ECG shown below. What is your comment on this ECG?

ECG Interpretation
At first glance: There is T wave inversion in anterior leads but you would expect this in a young girl. There are however T waves inverted in the lateral leads…….STOP. Let’s go over the ECG in a systematic fashion.
Is it sinus rhythm? For it to be sinus, the p wave in II must be upright and the p wave in aVR inverted. This is not the case. Now look at lead I, The p waves are inverted and they should be upright.
Two things give you this pattern:

1. Limb lead reversal and
2. Dextrocardia

This ECG is the result of limb lead reversal.
You have the ECG redone. The ECG is shown below. How would you comment on this?

Cardiac Bootcamp Self Study Course Members
should read the section on Paediatric ECG

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