Rhythm ECG Characteristics Example BAC 7-2013

Normal Sinus Rate: 60-100 per minute

Rhythm Rhythm: R- R =
P waves: Upright, similar
(NSR) P-R: 0.12 -0 .20 second
& consistent
QRS: 0.04 – 0.10 second
P: QRS : 1P:1 QRS
Sinus Rate: > 100
Tachycardia Rhythm: R- R =
Causes: P waves: Upright, similar
􀂉 Exercise
P-R: 0.12 -0 .20 second
􀂉 Hypovolemia & consistent
􀂉 Medications
QRS : 0.04 – 0.10 second
􀂉 Fever
P: QRS : 1P:1 QRS
􀂉 Hypoxia
􀂉 Substances
􀂉 Anxiety, Fear
􀂉 Acute MI
􀂉 Fight or Flight
Treatment: Treat the underlying cause first
􀂉 Congestive Heart Assess for hemodynamic compromise
Failure
Sinus Rate: < 60
Bradycardia Rhythm: R- R =
Causes: P waves: Upright; similar
􀂉 intrinsic sinus
P-R: 0.12 -0 .20 second
node & consistent
disease QRS : 0.04 – 0.10 second
􀂉 increased
P: QRS : 1P:1 QRS
parasympathetic
tone Treatment: None unless sx of hemodynamic compromise are present such as:
􀂉 drug effect – beta Chest pain, SOB, Altered LOC, hypotension, S&S of decreased perfusion
*Atropine to block vagal effect
blockers, calcium *Dopamine or Epinephrine may be used to increase HR and contractility
channel blockers *Pacing
**increased ICP,
vagal stim
Sinus P wave is normal in sinus beats,
Arrest/Pause absent in arrest beats
Causes – Or…may have a “non-conducted
-ischemia of SA node P”preceeding the arrest
-excessive vagal stim
-pericarditis PRI and QRS normal
-Dig Tox Treatm ent: Check drug levels
*Atropine
*Pacing

Wandering Rate: variable but usually 60-100

Atrial Pacer Rhythm: R-R may vary slightly
Causes: P waves: morphology varies
 Vagal Stim P-R varies slightly, < .20 seconds
QRS : 0.04 – 0.10 second
 Dig Toxicity
P: QRS 1P:1 QRS
 Rhumatic
heart

Treatm ent: usually none, discontinue digoxin if toxic

Premature Rate: usually < 100,

Atrial dependant
On underlying rhythm
Contractions Rhythm: irregular
(PAC) P waves: Early & upright,
Causes: different from Sinus
􀂉 normal
PR: 0.12 – 0.20 second;
􀂉 excessive use of
caffeine, stimulants, different from Sinus
tobacco, or alcohol QRS : 0.04 – 0.10 second Clinical Significance if > 6 per m inute
􀂉 CHF P: QRS = 1:1
Treatm ent: usually none required – m onitor
􀂉 Myocardial **discontinue stim ulant use
ischemia or
injury
􀂉 Hypokalemia, Dig
toxicity
􀂉 COPD
Atrial Flutter Rate: Atrial rate 250-350
Causes: Vent rate varies with block/conduction
􀂉 ischemic heart ***Controlled Rate- 60-100
***Rapid Ventricular Rate (RVR) >100
disease
􀂉 Hypoxia
Rhythm: Atrial = Regular
􀂉 Acute MI
Vent = Reg. or irreg
􀂉 Dig Toxicity
P waves: Not identifiable Treatment: treatment varies depending on duration of dysrhythmia
􀂉 Mitral or Tricuspid
F waves: Uniform (sawtooth *Amiodarone or antiarrhythmics to depress atrial irritability
valve *Calcium channel blocker or beta blocker for ventricular rate control if RVR
disease or picket fence )
*Anticoagulant therapy if prolonged rhythm
􀂉 Pulmonary PRI: not measurable **Cardioversion if unstable
embolism QRS : 0.04 – 0.10 second

Atrial Rate: Atrial: 400-600

Vent rate varies
Fibrillation ***Controlled Rate- 60-100
􀂉 Ischemic heart ***Rapid Ventricular Rate (RVR) >100
disease
􀂉 Hypoxia Rhythm: Atrial: irregular;
􀂉 Acute MI Vent.: irregular
􀂉 Digitalis toxicity P waves: No identifiable Ps
􀂉 Mitral or tricuspid f waves: may be seen. Treatment: treatment varies depending on duration of dysrhythmia
PRI: unable to measure *Amiodarone or antiarrhythmics to depress atrial irritability
disease *Calcium channel blocker or beta blocker for ventricular rate control if RVR
(No identifiable P) *Anticoagulant therapy if prolonged rhythm
QRS : usually normal **Cardioversion if unstable

SupraVentricular Rate: usually 150-260

Tachycardia Rhythm: Regular
(SVT) P waves: Not visible
or PR Interval: not measurable if SVT,
<0.12 if visible in PAT
Paroxysmal
QRS : usually normal
Atrial
Other: Onset may be sudden, often
Tachycardia initiated by a PAC
Causes:
􀂉 excessive use of
caffeine, stimulants, Treatment: Vagal maneuvers may be attempted
tobacco, or alcohol *Adenosine 6 mg rapid IVP followed by 20ml NS flush. May repeat once at 12 mg
rapid IVP followed by 20 ml NS flush. Conversion occurs 90% of the time when SVT
􀂉 CHF *Calcium channel blocker or beta blocker or digoxin for AV nodal blocking action
􀂉 Myocardial **Cardioversion if unstable
ischemia or injury
􀂉 Hypokalemia, Dig
toxicity
􀂉 COPD

Premature Rate: usually < 100,

Junctional dependant on the
underlying rhythm
Contraction Rhythm: irregular
(PJC) P waves: Inverted before or after
Causes: qRs or not visible
􀂉 excessive use of PR interval: < 0.12 second when
caffeine, stimulants, inverted P is before
tobacco, or alcohol QRS : 0.04 – 0.10 second
􀂉 CHF Clinical Significance if > 6 per m inute
P: QRS = 1:1 if Ps are visible
􀂉 Myocardial Treatm ent: usually none required – m onitor
ischemia -discontinue stim ulant use
􀂉 Hypokalemia, Dig - m onitor electrolytes
toxicity
􀂉 COPD
Junctional Rhythm: Regular
Rhythms P waves: Inverted before or after or
Causes: absent
􀂉 related to
PR interval: < 0.12 second when
medications- inverted P is before
Beta Blockers, QRS : 0.04 – 0.10 second
Calcium P: QRS 1:1 if Ps are visible Junctional Rhythm – Rate 40-60
Channel Blockers,
Dig
Toxicity Treatment:
􀂉 or increased
parasympathetic *Atropine for slow rhythms
tone *Pacing for slow rhythms with
􀂉 Acute Inferior
hemodynamic compromise
Wall MI Correct cause if possible Accelerated Junctional Rhythm – Rate 61-100
􀂉 Rheumatic Heart
Disease
􀂉 Post-Cardiac
*Cardizem, Beta blockers or digoxin
Surgery for rate control for fast rhythms
􀂉 Valvular Disease
Correct cause if possible

Junctional Tachycardia – Rate 101-180

Premature Rate: Dependent upon
Ventricular underlying rhythm
Complex (PVC) Rhythm: R – R ≠
P waves: Usually absent, if
Causes:
present, not associated
􀂉 Gastric overload
with PVC
􀂉 Stress UnifocaL Multifocal
QRS : 0.12 second or greater;
􀂉 Caffeine, Alcohol,
bizarre and notched Clinical significance >6 per minute
Nicotine
ST & T: Often opposite in
􀂉 Heart Disease Treatment: identify underlying cause
direction to the QRS
􀂉 Acid-Base **antiarrhythmics such as Amiodarone or Lidocaine
Imbalance Timing
􀂉 Electrolyte One on a strip = Rare
Imbalance One in a row = Isolated
􀂉 Cyclic
Two in a row = Pair, couplet
Antidepressants Three in a row = Salvo of VT
Bigem iny Trigem iny
􀂉 Hypoxia Pattern
􀂉 Acidosis Every other = Bigeminy
􀂉 Acute MI Every third = Trigeminy
Morphology
Similar shape = Uniformed Quadrigem iny Salvo
Different shape = Multiformed
Location
R – on – T = PVC falls on the T
wave
R on T – predisposes to other ventricular arrhythmias
Ventricular Rate: > 100 per minute and
Tachycardia usually not > 220
Causes: Rhythm: Usually regular
􀂉 Same as PVCs P Waves: ∅ P waves or if
􀂉 R on T present, not associated with qRs
Phenomenon QRS : Wide (≥ 0.12 sec),
bizarre Treatment: ***With pulse – synchronized cardioversion
 Antiarrhythmics such as Amiodarone
ST/T wave: Opposite direction
of qRs ***Pulseless - Defibrillation, CPR
A group of three PVCs in a row or Epinepherine or Vasopressin
Antiarrhythmics such as Amiodarone or Lidocaine
more at a rate greater than 100/
 minute or more constitutes
Ventricular Tachycardia.
Ventricular Rate: ∅
Fibrillation Rhythm: ∅ regularity,
Causes: chaotic undulating
􀂉 Acute Myocardial waves
Infarction P Waves: ∅
􀂉 Untreated QRS : ∅
Ventricular ST/T Wave: ∅ Treatm ent: Defibrillation, CPR
Tachycardia Epinepherine or Vasopressin
Organized activity: ∅ Antiarrhythmics such as Amiodarone or Lidocaine
􀂉 Hypothermia
No Cardiac Output or Pulse
􀂉 R-on-T PVCs
􀂉 Electrolyte
imbalance
􀂉 Electrical shock

Idioventricular Rate: 20-40 per minute

Rhythm Rhythm: R – R =
Causes: P waves: No P waves associated
􀂉 Myocardial
to qRs
Infarction QRS : > 0.12 sec, notched,
􀂉 Digitalis toxicity
bizarre appearance
􀂉 Metabolic
ST/T : Opposite direction of qRs
Rate > 40 to 100 = Accelerated Treatm ent: Code Blue, CPR
imbalances Epinepherine or Vasopressin
􀂉 Post resuscitation
rhythm

Agonal Rhythm Rate: <20 per minute

(Dying heart) Rhythm: irregular
Causes: P waves: No P waves
􀂉 Usually
QRS : > 0.12 sec,
progresses from bizarre appearance
Ventricular
Fibrillation Treatm ent: CPR
􀂉 Poor prognostic Epinepherine or Vasopressin

sign Do not defibrilate

Asystole Rate: Ventricular rate = 0
Causes: Rhythm: ∅ unless Ps are present,
􀂉 Extensive then regular or irregular
myocardial P waves: may be present
damage QRS : ∅
􀂉 Acute respiratory P:QRS ∅
failure
􀂉 Ischemia or
Infarction Treatm ent: CPR
Epinepherine or Vasopressin
􀂉 Traumatic cardiac
arrest Do not defibrilate
􀂉 Ventricular
aneurysm
􀂉 Countershock
􀂉 Hypoxia,
Hypothermia
􀂉 Hyperkalemia,
Hypokalemia
􀂉 Preexisting
acidosis
􀂉 Drug overdose

Pulseless Not a specific rhythm, but condition

Electrical is defined as an organized rhythm
Activity without a pulse.
Indicates mechanical failure of heart
(PEA) muscle
Causes: Cannot be diagnosed from monitor
􀂉 H’s & T’s
strip alone. Treatm ent: CPR
Epinepherine or Vasopressin

****Treat the cause*****

1st degree AV **1P : 1 QRS
Block **Prolonged PRI
Causes: (> 0.20 sec not > 0.40 sec)
􀂉 Ischemia or injury
to AV node
􀂉 Medications Treatment: Generally no treatment, monitor.
􀂉 Rhumatoid heart Discontinue toxic medications
disease
2nd degree AV ** More P waves than QRS
Block, **PRI progressively increases
in a cycle until P appears
Mobitz Type I w/o QRS .
(Wenckenbach) **Cyclic pattern reoccurs
Causes: **R – R ≠
􀂉 Ischemia or injury
to AV node or MI
􀂉 Medications
including dig Treatment: Generally no treatment except if rate is slow
toxicity Monitor patient
Discontinue toxic medications
􀂉 Excessive Vagal
Simulation

2nd degree AV **More P waves than qRs

Block, **PRI consistent
** QRS normal or wide (bundle
Mobitz Type II
branch block)
Causes:
** R - R≠ or R – R =
􀂉 Anterior MI

Treatment: Constant monitoring – may progress to 3 rd degree

Pacing
Atropine, dopamine or epinephrine if slow rate
3rd degree AV ** More P waves than QRS
Block ** P not r/t QRS
(P too close, P too far)
**PRI varies greatly
** QRS normal or wide
** R – R =

Treatment: Pacing
 Atropine, dopamine or epinephrine if slow rate

Paced rhythm
Pacer spike preceeds QRS, no p waves
present
QRS >.10
T wave opposite deflection of QRS
May be fixed or demand

Ventricular pacing

Atrial-Ventricular Pacing
Failure to Pacer spike occurs but no
Capture depolarization of muscle detected with
Causes: a QRS complex.
􀂉 Loss of contact by
electrode in muscle
􀂉 Failure of muscle
to respond to
electrical
stimulation
Failure to sense Pacer in “demand” mode fails to sense
Causes: the patient’s own intrinsic beat and
􀂉 Sensitivity mode fires causing competition problems
not set at correct between the pacer and heart
level or pacer
unable to “sense”
intrinsic heart rate
􀂉 displacement of
electrodes, battery
failure or lead wire
failure
Failure to Pace Lack of pacemaker produced
Causes: complexes on a cardiac monitor when
􀂉 Paer or battery there should be pacer activity.
failure and electrode
dysfunction