Normal Sinus Rhythm Sinus Arrest (a.k.a. sinus pause) occurs when the SA node fails to fire.
.k.a. sinus pause) occurs when the SA node fails to fire. NSR with First Degree AV Block
Sinus rhythm - also known as regular sinus rhythm (RSR) or normal
sinus rhythm (NSR) - is the most common adult rhythm with rates
between 60-100/minute. The QRS is most often narrow with upright P
waves in Lead II.
Sinus Bradycardia
Sinus Bradycardia with rates greater than 50/minute may be well
tolerated by healthy adults. Athletes may routinely be in sinus
bradycardia due to an optimal cardiac stroke volume that requires less
HR to yield acceptable cardiac output. Sinus bradycardia may also be
produced with Vagal stimulation or due to Sick Sinus Syndrome. Expect
a narrow QRS with upright P waves in Lead II.
Sinus Tachycardia
Sinus Tachycardia most often results from increased sympathetic
stimulation (i.e. due to pain, fever, increased oxygen demand, and/or
hypovolemia). It usually has a narrow QRS. The rate is often limited to
below 150 / minute.
Sinus Arrhythmia
Sinus Arrhythmia is most often a benign rhythm, common in children and
less common with older adults. The irregular pattern of this rhythm
fluctuates with inspiration (HR increases) and expiration (HR
decreases). A narrow QRS and upright P waves in Lead II is expected.
Sinus Exit Block
Sinus exit block (sinoatrial block) results from blocked sinus impulses -
impulses not getting through to depolarize the atria. While the sinus is
firing on schedule, the tissue around the SA node is not carrying the
impulse. The seriousness of this dysrhythmia is related to the frequency
and duration of the blocks. Note that each pause is equal to a multiple of
previous P-P intervals.
Sinus Arrest
The resulting pause is often NOT equal to the multiple of P-P intervals
seen in Sinus Exit Block. Instead, often an escape pacemaker such as
the AV junction will assume control of the heart. Again, like Sinus Exit
Block, treatment is related to the frequency and duration of the periods
of sinus arrest.
NSR with Premature Atrial Complexes
Premature Atrial Complexes or PAC result from irritability to the atria
resulting in increased automaticity of atrial tissue. Since the atria initiate
an impulse earlier than expected from the SA node, this is a premature
complex. Expect narrow QRS and flattened, notched, peaked or
biphasic P waves for the PAC.
SVT
Supraventricular tachycardia is an ominous rhythm with rates often
between 170-230 per minute. The telltale sign of supraventricular
tachycardia is the narrow QRS which defines its supraventricular origin
and its regular, rapid pattern. This rhythm is most likely not sinus
tachycardia due to its very fast rate. For those who are at rest, narrow
QRS tachycardias over 150 / minute are most often supraventricular
tachycardia
Atrial Fibrillation
Atrial fibrillation is a chaotic rhythm with recognizable QRS complexes.
The chaotic rhythm pattern and the absence of P waves are the
hallmarks of this dysrhythmia. The chaotic baseline - known as
fibrillatory waves - is quickly seen. Note: 1) atrial kick is lost here; and 2)
the risk of thrombus formation is particularly significant after 48 hours.
Atrial Flutter
Atrial flutter results from the development of a reentry circuit within the
atria generating a loop that discharges impulses at a flutter rate of 250-
350 / minute. Most often the AV junction passes every second (rate =
150, called a 2:1 response) or every fourth impulse (rate = 75, called a
4:1 response) through to the ventricles. Atrial flutter is readily identified
by the sawtooth baseline.
First degree AV block results from a prolonged transmission of the
electrical impulse through the AV junction (AV node and the Bundle of
His). The significant finding of this rhythm is a prolonged PR interval of
more than .20 seconds. The underlying rhythm should be identified and
named prior to claiming a first-degree AV block. For example, this
rhythm is a normal sinus rhythm WITH a first-degree AV block.
2nd Degree AV Block Type I
Second degree AV block Type I (Wenckebach or Mobitz Type I) results
from a cyclical and progressive conduction delay through the AV
junction. The ECG presents with a cyclical lengthening of the PR interval
followed by a dropped QRS - a P wave not partnered with a QRS. The
QRS complexes yield an irregular rhythm. Second degree AV block
Type I may be caused by enhanced vagal tone, myocardial ischemia or
the effects of drugs such as calcium-channel blockers, digitalis and beta-
blockers.
2nd Degree AV Block Type II
Second Degree AV Block Type II is typically caused by an intermittent
block (interrupted supraventricular impulse) below the AV node. One or
more QRS complexes are dropped with PR intervals that do not change
(fixed PR interval). This irregular rhythm requires close monitoring: 1)
low cardiac output is likely when multiple dropped QRS complexes
occur; and 2) this rhythm can progress to complete heart block (third
degree AVB).
Third Degree AV Block
Third degree AV block (complete heart block) is often an ominous
rhythm requiring close monitoring for hemodynamic compromise,
progression to ventricular standstill or asystole and other lethal
dysrhythmias. Significant characteristics of this rhythm are: 1) lonely P
waves - P wave without an accompanied QRS complex; and 2) chaotic
PR intervals. A narrow QRS denotes a higher junctional block while a
wide QRS points more towards a sub-nodal block high in the bundle
branches.
NSR with Premature Ventricular Complex
Premature ventricular complexes (PVC) often represent increased
ventricular automaticity or reentry phenonomen. The presence of PVCs
may be benign but can indicate irritable ventricles. PVCs arrive earlier
than expected and is usually wide (.12 seconds or more). Note that the T
wave often points in an opposite direction from the QRS complex. A
PVC every second complex is called ventricular bigeminy...every 3rd -
ventricular trigeminy.
Ventricular Asystole (flatline)
Idioventricular Rhythm
Idioventricular rhythm (IVR) occurs when the SA and AV nodes are
either NOT firing or firing slower than the ventricular pacemaker rate. A
common ventricular pacemaker rate is 20-40 / minute, a rate that is often
not sufficient to sustain an adequate cardiac output.

Premature Junctional Complex

A PJC arises from an irritable focus within the AV junction.
Characteristics of a PJC include: 1) an absent or inverted P wave in lead
II; 2) a shortened PR interval - less than .12 seconds; and 3) the
complex comes early or premature
Junctional Rhythm
Junctional rhythm - also called junctional escape rhythm - originates
from the AV junction (AV node and Bundle of His). The expected
pacemaker rate of the AV junction is 40-60 / minute. In lead II, a
junctional rhythm presents with inverted or absent P waves. Note: an
absent P wave in junctional rhythm is also associated with loss of atrial
kick.
Accelerated Junctional
Accelerated junctional rhythm results from enhanced automaticity,
increased sympathetic nervous system activity (catecholamines) or
ischemia. Key features of this rhythm include a rate between 60-100 /
minute, inverted or absent P waves (in lead II) , shortened PR interval,
and QRS complexes that are usually narrow.
Accelerated Idioventricular Rhythm
Accelerated idioventricular rhythm (AIVR) is a ventricular rhythm
occuring at a rate between 41-100 / minute - faster than typical
pacemaker rates expected of the ventricles (20-40 / minute) and less
than what is considered a tachycardia (>100 / minute). Enhanced
automaticity - possibly due to hypoxia or abundant sympathetic
stimulation - increases rate of ventricular electrical impulses. Note that
this rhythm is often unstable and can move quickly to either asystole or
ventricular tachycardia (VT).
Ventricular Tachycardia
Ventricular tachycardia (VT) often results in hemodynamic compromise
(due to minimal ventricular filling time and the absence of atrial kick).
What makes this rhythm more ominous is its tendency to transition into
ventricular fibrillation. Causes of VT include myocardial ischemia, a PVC
landing on a T wave (R-on-T ), cardiac drug toxicity and electrolyte
imbalance. Non-sustained VT (a group of 3 or more PVCs) is a run of
VT.

Ventricular Fibrillation
Ventricular fibrillation (VFib) is a chaotic rhythm originating in the
ventricles, resulting in no cardiac output. Coarse VFib is noted when the
amplitude (height) of the rhythm is equal to or more than 3 mm. Fine
Junctional Tachycardia VFib is less than 3 mm in height and signifies less electrical energy
within the myocardium - less opportunity for a successful defibrillation.

Wandering Pacemaker
A wandering pacemaker rhythm is a supraventricular rhythm with
varying locations of impulse formation resulting in three or more different
P waves. With a narrow QRS complex, the absence of a P wave
qualifies as one type of P wave. In the rhythm above, note the P waves
from the sinus node, the atria and the junction.