RHYTHM

Normal Sinus Rhythm

Look at the p waves:
✔rate is 60-100/min
✔cycle length do not vary by 10%
✔PR interval is 0.12 sec. or more

Lead II
 Normal Sinus Rhythm
Look at the p waves:
✔same contour in same lead?
✔Upright in I, II, aVF & left precordial
leads
✔followed by QRST?
Lead II
 Sinus Bradycardia

hRegularly occurring PQRST

hRate < 60 / min

Rate = 48/min
Rate = 48/min
Sinus Bradycardia
 Sinus Tachycardia

hRegularly occurring PQRST

hRate > 100 / min

Rate = 111/min Rate = 111/min Rate = 111/min

Sinus Tachycardia
 Sinus Arrhythmia
hIdentical but irregularly
occurring PQRST
hlongest PP or RR > the
shortest by 0.16 sec or more
Rate = 71/min
Rate = 94/min Rate = 94/min
Rate = 79/min
Sinus Arrhythmia
Coronary Sinus Rhythm

hRegularly occurring PQRST

hInverted P waves at II, III, AVF
Coronary Sinus Rhythm
 Premature Atrial Contraction

hPrematurely occurring PQRTS complex

hP wave different in configuration
from the sinus beat.
hPR interval often long.
hQRS narrow.
 Wandering Atrial
Pacemaker
hVariable P wave morphology
hImpulses originate from varying
points in the atrium
 Wandering Atrial
Pacemaker
hVariable P wave morphology
hImpulses originate from varying
points in the atrium
Wandering Atrial Pacemaker
 Multifocal Atrial
Tachycardia
hImpulses originate irregularly
and rapidly at different points
in the atrium
hVarying P wave, PR, PP and RR intervals
hVentricular rate > 100/min
Multifocal Atrial Tachycardia
Paroxysmal Supraventricular Tachycardia
 AVN Conduction
(N) AVN Conduction
with unilateral block

b pathway
b pathway
a pathway
a pathway

AV NODE
 Atrial Flutter

hAtrial rate = 220-300/min

( P as flutter waves )
hVariable degree of AV block
( irregular RR interval )
Atrial Flutter
Atrial Fibrillation

hNo discernible P waves

hIrregular RR interval
Atrial Fibrillation
Junctional Rhythm

hImpulses from the AV node

hP wave inverted or buried w/in
QRS or follows the QRS
hRate slow
hQRS narrow
Junctional Rhythm
Junctional Premature
Contraction
hPrematurely occurring PQRST.
hInverted P wave that may precede,
be incorporated within, or may follow
the QRS complex.
hQRS narrow.
 Multifocal Premature Ventricular
Contraction
hPVC’s coming from different foci in
the ventricle
hPVC’s assuming different polarities
in a single lead
hPVC’s of different morphology and
coupling interval
 Premature Ventricular Contraction
R on T Phenomenon

hR or Q of the PVC occurring at the

T wave of the preceding sinus beat
hMost dangerous PVC
 Ventricular Tachycardia

hAt least 3 consecutive PVC’s

hRapid, bizarre, wide QRS complexes
(> 0.10 sec)
hNo P wave (ventricular impulse
origin)

Rate > 140 / min

 Premature Ventricular Contraction
in Couplets

hTwo Premature ventricular

contractions occurring consecutively
 Premature Ventricular Contraction
in Bigeminy

hAlternating normal sinus beat and

a PVC
 Premature Ventricular Contraction
in Trigeminy

hPVC’s regularly occurring every

third beat
 Premature Ventricular Contraction
in Quadrigeminy

hPVC’s regularly occurring every

fourth beat
 Multifocal Premature Ventricular
Contraction
hPVC’s coming from different foci in
the ventricle
hPVC’s assuming different polarities
in a single lead
hPVC’s of different morphology and
coupling interval
 Premature Ventricular Contraction
R on T Phenomenon

hR or Q of the PVC occurring at the

T wave of the preceding sinus beat
hMost dangerous PVC
 Ventricular Tachycardia

hAt least 3 consecutive PVC’s

hRapid, bizarre, wide QRS complexes
(> 0.10 sec)
hNo P wave (ventricular impulse
origin)

Rate > 140 / min

Ventricular Tachycardia
 Ventricular Fibrillation

hAssociated with coarse or fine chaotic

undulations of the ECG baseline
hNo P wave
hNo true QRS complexes
hIndeterminate rate

Coarse Fibrillation Fine Fibrillation

Ventricular Fibrillation
 Idioventricular Rhythm
hImpulse ventricular in origin
hAbsence of (N), upright P wave
associated with QRS complexes
hQRS > 0.10 sec
hT wave opposite in direction to QRS
hRate < 40 / min
Rate < 48 / min
Accelerated Idioventricular Rhythm

hImpulse ventricular in origin

hAbsence of (N), upright P wave
associated with QRS complexes
hQRS > 0.10 sec
hT wave opposite in direction to QRS
hRate = 40-120 / min

Rate = 40-120 / min

Accelerated Idioventricular Rhythm
hWith 2 foci of ventricular activity
Intraventricular Conduction Delay

hSupraventricular rhythm with

associated BBB
hWide QRS complexes
 Agonal Rhythm
hExtreme sinus bradycardia with irregular, idioventricular
rhythm and occasional atrial activity
 Wolf Parkinson White Syndrome

hSupraventricular rhythm with wide

QRS complex because of pre-excitation
hShort or no PR segment followed by a
delta wave (slurred upstroke of QRS)
The PR Interval
 DO remember
The AV node is
the normal link
between the
atria &
ventricles!
 PR INTERVAL

0.12 secs.

0.20 secs.
 PR INTERVAL

Where to
measure:
standard or uni-
polar limb lead
with the longest
PR interval
 DO remember
Short PR means
bypass of the AV
node; too long
means block!
FIRST DEGREE
AV BLOCK
hPR interval > 0.20 sec

0.28 sec 0.28 sec 0.28 sec

FIRST DEGREE AV BLOCK
 Second Degree
Atrioventricular Blocks

Do you have a normal P wave? Yes

Do you have a normal PR segment? No
Do you have a normal PR interval? No
Will there be intermittent P waves not
followed by QRS complex? Yes (dropped beats)
 SECOND DEGREE AV BLOCK
MOBITZ I

hProgressive lengthening
of PR interval w/ intermittent
drop beats .

0.20 sec 0.28 sec 0.20 sec

SECOND DEGREE BLOCK AT THE
AV BLOCK
MOBITZ II hBundle of His
hBilateral bundle
branches
hFixed PR interval hTrifascicle
w/ intermittent
drop beats .

0.18 sec 0.18 sec 0.18 sec

HIGH GRADE AV BLOCK
 THIRD DEGREE
AV BLOCK
hComplete atrioventricular block
hImpulses originate at both SA node and at
the subsidiary pacemaker below the block
Do you have regularly occurring P waves and QRS complexes? Yes
Are the P waves related to the QRST complexes? No
Is the atrial rate < = > ventricular rate? greater

Ventricular rate = 83 BPM Ventricular rate = 83 BPM

Atrial rate = 100 BPM Atrial rate = 100 BPM

Atrial rate = 100 BPM