Cardiac Rhythms and Dysrhythmias

Rhythm and Strip ECG Characteristics Management

Normal sinus rhythm Rate: 60 – 100 bpm This is a normal heart rhythm so no
Rhythm: regular treatment is required
There is one P for every QRS
PR interval: 0.12 – 0.20 seconds
QRS complex: 0.06 – 0.10 seconds

Sinus tachycardia Rate: 101 – 150 bpm This is only treated if client is
Rhythm: regular symptomatic or is at risk for
There is one P for every QRS but may myocardial damage
be hidden with T wave due to speed If there is an underlying cause, beta-
PR interval: 0.12 – 0.20 seconds blockers or verapamil can be used
QRS complex: 0.06 – 0.10 seconds
Sinus bradycardia Rate: < 60 bpm This is only treated if client is
Rhythm: regular symptomatic; administer IV atropine,
There is one P for every QRS isoproterenol, and/or pacemaker may
be used
PR interval: 0.12 – 0.20 seconds
QRS complex: 0.06 – 0.10 seconds

Premature atrial contractions (PAC) Rate: varies This usually requires no treatment.
Rhythm: regular with early beats Advise client to reduce alcohol intake,
originating in atria reduce stress, and stop smoking
There is one P for every QRS
PR interval: not measured
QRS complex: 0.06 – 0.10 seconds
Atrial flutter Rate: atrial 240 – 360 bpm, ventricular This is treated with synchronized
rate depends on degree of AV block cardioversion; meds to reduce
Rhythm: regular ventricular response such as beta-
P:QRS ratio: 2:1. 4:1, 6:1, or variable blocker or calcium channel blocker
PR interval: not measured followed by a class I antidysrhythmic
or amiodarone
QRS complex: 0.06 – 0.10 seconds
Atrial fibrillation Rate: 300 – 600 bpm; ventricular 100 – This is treated with synchronized
180 bpm in untreated clients cardioversion; meds to reduce
Rhythm: irregularly regular ventricular response rate such as
P:QRS ratio is variable metoprolol, diltiazem, or digoxin;
anticoagulant therapy to reduce risk of
PR interval: not measured
clot formation and stroke
QRS complex: 0.06 – 0.10 seconds

Premature ventricular contractions (PVC) Rate: variable This is treated if client is symptomatic;
Rhythm: irregular; PVC interrupts advise against using stimulants
underlying rhythm and followed by a (caffeine, nicotine); drug therapy
compensatory pause includes, class I and III
No P wave noted before a PVC antidysrhythmics and possibly addition
of a beta blocker
PR interval: absent
QRS complex: wide, > 0.12 seconds
Ventricular tachycardia Rate: 100 – 250 bpm This is treated if VT is sustained or if
Rhythm: regular client is symptomatic; treatment
No indentifiable P wave includes IV procainamide, lidocaine.
PR interval: not measured If unstable, a class III antidysrhythmic
and immediate cardioversion; ablation
QRS complex: ≥ 0.12 seconds; bizarre
surgery or internal defibrillator for
shape
repeated episodes
Ventricular fibrillation Rate: too rapid to count Immediate defibrillation
Rhythm: grossly irregular
No identifiable P waves
PR interval: none
QRS complex: bizzare, varying in
shape and direction
First-degree AV block Rate: 60 – 10 bpm No treatment required
Rhythm: regular
There in one P for every QRS
PR interval: > 0.20 seconds
QRS complex: 0.06 – 0.10 seconds
Second-degree AV block type 1 (Mobitz 1, Wenckebach) Rate: 60 – 100 bpm Treatment includes monitoring and
Rhythm: atrial regular, ventricular observation; atropine and isoproterenol
irregular if client is symptomatic (rarely
P:QRS ratio: 1:1 until P wave is progresses to a higher level of block)
blocked w/ no QRS following
PR interval: progressively lengthens in
regular pattern
QRS complex: 0.06 – 0.10 seconds;
sudden absence of QRS complex
Second-degree AV block type 2 (Mobitz 2) Rate: atrial 60 -100 bpm, ventricular < Treatment includes atropine or
60 bpm isoproterenol; pacemaker therapy
Rhythm: atrial regular, ventricular
irregular
P:QRS ration: typically 2:1, may vary
PR interval: constant PR interval for
each conducted QRS
QRS complex: 0.06 – 0.10 seconds
Third-degree block (complete heart block) Rate: atrial 60 – 100 bpm; ventricular Immediate pacemaker therapy
15 – 60 bpm
Rhythm: both atrial and ventricular are
regular
Independent rhythm (no relationship
between P and QRS)
PR interval: not measured
QRS complex:
ECG RHYTHMS

This section will cover some of the most common ECG patterns that you'll come across on an ambulance.

Normal Sinus Rhythm

Looking at the ECG you'll see that:

 Rhythm - Regular
 Rate - (60-100 bpm)
 QRS Duration - Normal
 P Wave - Visible before each QRS complex
 P-R Interval - Normal (<5 small Squares. Anything above and this would be 1st degree block)
 Indicates that the electrical signal is generated by the sinus node and travelling in a normal fashion
in the heart.

 Sinus Bradycardia

A heart rate less than 60 beats per minute (BPM). This in a healthy athletic person may be 'normal',
but other causes may be due to increased vagal tone from drug abuse, hypoglycaemia and brain
injury with increase intracranial pressure (ICP) as examples

Looking at the ECG you'll see that:

 Rhythm - Regular
 Rate - less than 60 beats per minute
 QRS Duration - Normal
 P Wave - Visible before each QRS complex
 P-R Interval - Normal
 Usually benign and often caused by patients on beta blockers

 Sinus Tachycardia
 An excessive heart rate above 100 beats per minute (BPM) which originates from the SA node.
Causes include stress, fright, illness and exercise. Not usually a surprise if it is triggered in response
to regulatory changes e.g. shock. But if their is no apparent trigger then medications may be
required to suppress the rhythm

Looking at the ECG you'll see that:

 Rhythm - Regular
 Rate - More than 100 beats per minute
 QRS Duration - Normal
 P Wave - Visible before each QRS complex
 P-R Interval - Normal
 The impulse generating the heart beats are normal, but they are occurring at a faster pace than
normal. Seen during exercise

 Supraventricular Tachycardia (SVT) Abnormal

A narrow complex tachycardia or atrial tachycardia which originates in the 'atria' but is not under
direct control from the SA node. SVT can occur in all age groups

Looking at the ECG you'll see that:

 Rhythm - Regular
 Rate - 140-220 beats per minute
 QRS Duration - Usually normal
 P Wave - Often buried in preceding T wave
 P-R Interval - Depends on site of supraventricular pacemaker
 Impulses stimulating the heart are not being generated by the sinus node, but instead are coming
from a collection of tissue around and involving the atrioventricular (AV) node

 Atrial Fibrillation
 Many sites within the atria are generating their own electrical impulses, leading to irregular
conduction of impulses to the ventricles that generate the heartbeat. This irregular rhythm can be
felt when palpating a pulse

Looking at the ECG you'll see that:

 Rhythm - Irregularly irregular

 Rate - usually 100-160 beats per minute but slower if on medication
 QRS Duration - Usually normal
 P Wave - Not distinguishable as the atria are firing off all over
 P-R Interval - Not measurable
 The atria fire electrical impulses in an irregular fashion causing irregular heart rhythm

 Atrial Flutter

Looking at the ECG you'll see that:

 Rhythm - Regular
 Rate - Around 110 beats per minute
 QRS Duration - Usually normal
 P Wave - Replaced with multiple F (flutter) waves, usually at a ratio of 2:1 (2F - 1QRS) but
sometimes 3:1
 P Wave rate - 300 beats per minute
 P-R Interval - Not measurable
 As with SVT the abnormal tissue generating the rapid heart rate is also in the atria, however, the
atrioventricular node is not involved in this case.

 1st Degree AV Block
 1st Degree AV block is caused by a conduction delay through the AV node but all electrical signals
reach the ventricles. This rarely causes any problems by itself and often trained athletes can be
seen to have it. The normal P-R interval is between 0.12s to 0.20s in length, or 3-5 small squares
on the ECG.

Looking at the ECG you'll see that:

 Rhythm - Regular
 Rate - Normal
 QRS Duration - Normal
 P Wave - Ratio 1:1
 P Wave rate - Normal
 P-R Interval - Prolonged (>5 small squares)

 2nd Degree Block Type 1 (Wenckebach)

Another condition whereby a conduction block of some, but not all atrial beats getting through to
the ventricles. There is progressive lengthening of the PR interval and then failure of conduction of
an atrial beat, this is seen by a dropped QRS complex.

Looking at the ECG you'll see that:

 Rhythm - Regularly irregular

 Rate - Normal or Slow
 QRS Duration - Normal
 P Wave - Ratio 1:1 for 2,3 or 4 cycles then 1:0.
 P Wave rate - Normal but faster than QRS rate
 P-R Interval - Progressive lengthening of P-R interval until a QRS complex is dropped

 2nd Degree Block Type 2
 When electrical excitation sometimes fails to pass through the A-V node or bundle of His, this
intermittent occurance is said to be called second degree heart block. Electrical conduction usually
has a constant P-R interval, in the case of type 2 block atrial contractions are not regularly followed
by ventricular contraction

Looking at the ECG you'll see that:

 Rhythm - Regular
 Rate - Normal or Slow
 QRS Duration - Prolonged
 P Wave - Ratio 2:1, 3:1
 P Wave rate - Normal but faster than QRS rate
 P-R Interval - Normal or prolonged but constant

 3rd Degree Block

3rd degree block or complete heart block occurs when atrial contractions are 'normal' but no
electrical conduction is conveyed to the ventricles. The ventricles then generate their own signal
through an 'escape mechanism' from a focus somewhere within the ventricle. The ventricular escape
beats are usually 'slow'

Looking at the ECG you'll see that:

 Rhythm - Regular
 Rate - Slow
 QRS Duration - Prolonged
 P Wave - Unrelated
 P Wave rate - Normal but faster than QRS rate
 P-R Interval - Variation
 Complete AV block. No atrial impulses pass through the atrioventricular node and the ventricles
generate their own rhythm

 Bundle Branch Block
 Abnormal conduction through the bundle branches will cause a depolarization delay through the
ventricular muscle, this delay shows as a widening of the QRS complex. Right Bundle Branch Block
(RBBB) indicates problems in the right side of the heart. Whereas Left Bundle Branch Block (LBBB)
is an indication of heart disease. If LBBB is present then further interpretation of the ECG cannot be
carried out.

Looking at the ECG you'll see that:

 Rhythm - Regular
 Rate - Normal
 QRS Duration - Prolonged
 P Wave - Ratio 1:1
 P Wave rate - Normal and same as QRS rate
 P-R Interval - Normal

 Premature Ventricular Complexes

Due to a part of the heart depolarizing earlier than it should

Looking at the ECG you'll see that:

 Rhythm - Regular
 Rate - Normal
 QRS Duration - Normal
 P Wave - Ratio 1:1
 P Wave rate - Normal and same as QRS rate
 P-R Interval - Normal
 Also you'll see 2 odd waveforms, these are the ventricles depolarising prematurely in response to a
signal within the ventricles.(Above - unifocal PVC's as they look alike if they differed in appearance
they would be called multifocal PVC's, as below)
 

Junctional Rhythms

Looking at the ECG you'll see that:

 Rhythm - Regular
 Rate - 40-60 Beats per minute
 QRS Duration - Normal
 P Wave - Ratio 1:1 if visible. Inverted in lead II
 P Wave rate - Same as QRS rate
 P-R Interval - Variable
 Below - Accelerated Junctional Rhythm

Ventricular Tachycardia (VT) Abnormal

Looking at the ECG you'll see that:

 Rhythm - Regular
 Rate - 180-190 Beats per minute
 QRS Duration - Prolonged
 P Wave - Not seen
 Results from abnormal tissues in the ventricles generating a rapid and irregular heart rhythm. Poor
cardiac output is usually associated with this rhythm thus causing the pt to go into cardiac arrest.
Shock this rhythm if the patient is unconscious and without a pulse

 Ventricular Fibrillation (VF) Abnormal

Disorganised electrical signals cause the ventricles to quiver instead of contract in a rhythmic
fashion. A patient will be unconscious as blood is not pumped to the brain. Immediate treatment by
defibrillation is indicated. This condition may occur during or after a myocardial infarct.

Looking at the ECG you'll see that:

 Rhythm - Irregular
 Rate - 300+, disorganised
 QRS Duration - Not recognisable
 P Wave - Not seen
 This patient needs to be defibrillated!! QUICKLY

 Asystole - Abnormal

Looking at the ECG you'll see that:

 Rhythm - Flat
 Rate - 0 Beats per minute
 QRS Duration - None
 P Wave - None
 Carry out CPR!!

 Myocardial Infarct (MI)
 Looking at the ECG you'll see that:

 Rhythm - Regular
 Rate - 80 Beats per minute
 QRS Duration - Normal
 P Wave - Normal
 S-T Element does not go isoelectric which indicates infarction

Info

ECG Component Time(sec) Small Squares

P Wave 0.10 up to 2.5

PR Interval 0.12 - 0.20 2.5-5.0

QRS 0.10 1.5-2.5

Normal ECG

A normal ECG is illustrated above. Note that the heart is beating in a regular sinus rhythm between 60 -
100 beats per minute (specifically 82 bpm). All the important intervals on this recording are within normal
ranges.

1. P wave:

 upright in leads I, aVF and V3 - V6

 normal duration of less than or equal to 0.11 seconds
 polarity is positive in leads I, II, aVF and V4 - V6; diphasic in leads V1 and V3; negative in aVR
 shape is generally smooth, not notched or peaked

2. PR interval:

 Normally between 0.12 and 0.20 seconds.

3. QRS complex:

 Duration less than or equal to 0.12 seconds, amplitude greater than 0.5 mV in at least one
standard lead, and greater than 1.0 mV in at least one precordial lead. Upper limit of normal
amplitude is 2.5 - 3.0 mV.
 small septal Q waves in I, aVL, V5 and V6 (duration less than or equal to 0.04 seconds;
amplitude less than 1/3 of the amplitude of the R wave in the same lead).
 represented by a positive deflection with a large, upright R in leads I, II, V4 - V6 and a negative
deflection with a large, deep S in aVR, V1 and V2
 in general, proceeding from V1 to V6, the R waves get taller while the S waves get smaller. At V3
or V4, these waves are usually equal. This is called the transitional zone.

4. ST segment:

 isoelectric, slanting upwards to the T wave in the normal ECG

  can be slightly elevated (up to 2.0 mm in some precordial leads)
 never normally depressed greater than 0.5 mm in any lead

5. T wave:

 T wave deflection should be in the same direction as the QRS complex in at least 5 of the 6 limb
leads
 normally rounded and asymmetrical, with a more gradual ascent than descent
 should be upright in leads V2 - V6, inverted in aVR
 amplitude of at least 0.2 mV in leads V3 and V4 and at least 0.1 mV in leads V5 and V6
 isolated T wave inversion in an asymptomatic adult is generally a normal variant

6. QT interval:

 Durations normally less than or equal to 0.40 seconds for males and 0.44 seconds for females.