Delayed defibrillation caused by unexpected ECG artifact

Ann Emerg Med. 2008 Nov;52(5):515-8. doi: 10.1016/j.annemergmed.2008.02.008. Epub 2008 Apr 3.


Incorrect lead selection and unexpected ECG artifact during an attempted resuscitation after inhospital cardiac arrest resulted in undetected lack of cardiac monitoring for approximately 13 minutes. The patient was finally countershocked and regained a spontaneous pulse but was determined to have experienced profound neurologic damage and died shortly after being extubated. This type of failure may be common, particularly with older monitor/defibrillators. Caregivers, health care organizations, and device manufacturers should be aware of this potential problem and institute preventive measures.

Publication types

  • Case Reports

MeSH terms

  • Adult
  • Diagnostic Errors*
  • Electric Countershock / adverse effects
  • Electric Countershock / methods*
  • Electrocardiography / adverse effects*
  • Fatal Outcome
  • Female
  • Heart Arrest / therapy*
  • Humans