Systematic Analysis of Cardiac Rhythms Module One: Sinus Rhythms

Normal Sinus Rhythm: Rhythm: Regular Rate: 60-100 bpm P Wave: Uniform in appearance; Small, rounded and precedes each QRS PR interval: 0.12-0.20 QRS duration: less than 0.12

Sinus Dysrhythmia: Rhythm: Rate: P Wave: PR interval: QRS duration:

Irregular in a cyclic, predictable way; related to respiration Typically 60-100 bpm, but may also occur in sinus bradycardia Small, rounded and precedes each QRS 0.12-0.20 less than 0.12

Sinus Bradycardia: Rhythm: Rate: P Wave: PR interval: QRS duration:

Regular Less than 60 bpm Small, rounded and precedes each QRS 0.12-0.20 less than 0.12

Sinus Tachycardia: Rhythm: Rate: P Wave: PR interval: QRS duration:

Regular 101-160 bpm Small, rounded and precedes each QRS 0.12-0.20 less than 0.12

Module Two: Atrial Rhythms Premature Atrial Complexes (PACs): Rhythm: Underlying sinus rhythm is usually regular; premature beats will be associated with a pause making rhythm irregular. Rate: Underlying rhythm is usually 60-100 P Wave: Premature P wave will be unlike the normal sinus P wave PR interval: Normal of 0.12-0.20 in underlying rhythm, interval may be shorter for PACs QRS duration: 0.12 or greater

Atrial Tachycardia: Rhythm: Rate: P Wave: PR interval: QRS duration:

(Also known as Supra-ventricular tachycardia/SVT) Regular 160-220 bpm P wave not like the normal sinus P wave; abnormal P wave that is often pointed, precedes each QRS Shortened and may not be able to be measured 0.06-0.10

Atrial Flutter: Rhythm: Rate: P Wave: PR interval: QRS duration:

Varies Two rates are measured: (1) atrial flutter waves will usually have a rate of 220-350 bpm; (2) ventricular rate varies , 1/3, or of atrial rate but usually between 60-150bpm. No identifiable P wave; saw- tooth or flutter or F waves are present Not measurable less than 0.12

Atrial Fibrillation: Rhythm: Irregular Rate: Atrial rate cannot be counted, ventricular rate will vary but about 120-160 impulses. P Wave: No identifiable P wave PR interval: Not measurable QRS duration: less than 0.12

Wandering Atrial Pacemaker: Rhythm: Irregular Rate: Usually 60-100, not greater than 100 P Wave: P wave vary in appearance. PR interval: Varies QRS duration: less than 0.12

Module Three: Junctional Rhythms and AV Blocks Premature Junctional Contractions (PJCs): Rhythm: Underlying sinus rhythm is usually regular; premature beats will be associated with a pause making rhythm irregular. Rate: Underlying rhythm is usually 60-100 P Wave: The premature P wave is unlike the normal sinus P wave; P wave may be absent or inverted; if a P wave is present it may occur close to the QRS, may be hidden in the QRS, or occur after the QRS PR interval: Normal of 0.12-0.20 in underlying rhythm, shorter for PACs; less than QRS duration: Usually normal

Junctional Rhythm: (Also called Junctional Escape Rhythm) Rhythm: Regular Rate: Underlying rhythm is usually 40-60 P Wave: If a P wave is present it is unlike the normal sinus P wave; P wave may be absent or inverted; if a P wave is present it may occur before, during, or after the QRS PR interval: Shorter than 0.12 or shorter than 0.10 QRS duration: less than 0.12

Junctional Tachycardia: Rhythm: Regular Rate: 120-200 bpm P Wave: If a P wave is present it is unlike the normal sinus P wave; P wave may be absent or inverted; if a P wave is present it may occur before, during, or after the QRS PR interval: Shorter than 0.12 QRS interval: less than 0.12

First-Degree AV Block: Rhythm: Regular Rate: Usually 60-100, but may be slower P Wave: Normal PR interval: Prolonged, greater than 0.20 sec QRS duration: less than 0.12

Second-Degree AV Block Type I: Wenkebach, also known as Mobitz I Rhythm: Irregular, irregularity may appear predictable or patterned (regularly irregular) Rate: Usually within normal range P Wave: Normal PR interval: Prolongs beat to beat until you see a P wave with no QRS to follow QRS duration: less than 0.12

Second-Degree AV Block Type II: also known as Mobitz II Rhythm: Irregular Rate: Usually within normal range P Wave: Normal PR interval: PR is greater than 0.20; prolonged PR is consistent beat to beat then unexpectedly you see a P wave with no QRS to follow QRS duration: 0.12 or greater

Third Degree AV Block or complete heart block: Rhythm: P to P is regular, QRS to QRS is regular Rate: There are two different rates; must measure P to P to find atrial rate and QRS to QRS to find ventricular rate. These two rates will usually be different. P Wave: Normal PR interval: Do not measure the PR in Third Degree AV Block. There is no relationship between the Ps and QRSs. QRS duration: it could be narrow less than 0.12 seconds or wide 0.12 seconds or greater

Module Four: Ventricular Rhythms Premature Ventricular Complexes (PVCs): Rhythm: Underlying sinus rhythm is usually regular; premature beats will be associated with a pause making rhythm irregular Rate: Underlying rhythm is usually 60-100 P Wave: P wave is normal in the underlying rhythm; no P wave with premature beats; pause to follow premature beats PR interval: Normal of 0.12-0.20 in underlying rhythm QRS duration: 0.06-0.10 in the underlying rhythm; QRS of the PVC will be 0.12 or greater

Ventricular Tachycardia: Rhythm: Regular Rate: 140-200 bpm P Wave: None; because they are buried in the QRS complexes making them obscure PR interval: None QRS duration: Greater than 0.12 sec

Ventricular Fibrillation: Rhythm: Chaotic rhythm, wavy baseline Rate: No ability to measure atrial or ventricular rate P Wave: None PR interval: None QRS duration: None

Asystole: Rhythm: Rate: P Wave: PR interval: QRS duration:

No rhythm, flat line No ability to measure atrial or ventricular rate None None Non3