Basic Arrhythmia Rules

Basic Arrhythmia Course Exam: 10 October 2008

Eina Jane & Co. © 2008 Last Updated: 06 October 2008

Walraven, G. (2006). Basic arrhythmias. Upper Saddle River, New Jersey: Brady Prentice Hall/Health.

Sinus P before QRS, then T Morphing P; hidden, lost in T Inverted P; before, during/hidden, after QRS

Normal Sinus Rhythm

Regular 60‐100 bpm

P Wave: normal upright

PRI: 0.12‐0.20s

QRS: <0.12s

Wandering Pacemaker

Slightly irregular 60‐100 bpm

P Wave: morphology changes, difficult

to see, change every complex

PRI: 0.12‐0.20s, changes every complex

QRS: <0.12s

Premature Junctional Contraction

Underlying rhythm and rate

P Waves: inverted; before, during, after

QRS

PRI: measured before QRS, <0.12s

QRS: <0.12s

Sinus Bradycardia

Regular <60 bpm


PRI: 0.12‐0.20s

QRS: <0.12s

Premature Atrial Contraction

Regular underlying except for PAC,

60‐100 bpm, just one beat

P Wave: flattened, notched, lost in T

wave

PRI: 0.12‐0.20s, >0.20s

QRS: <0.12s

Junctional Escape Rhythm

Regular 40‐60 bpm


QRS


QRS: <0.12s

Sinus Tachycardia

Regular >100 bpm


PRI: 0.12‐0.20s

QRS: <0.12s

Atrial Tachycardia


P Wave: different, lost in T wave

PRI: 0.12‐0.20s

QRS: <0.12s

Accelerated Junctional Rhythm



QRS


QRS: <0.12s

Sinus Arrhythmia

Irregular 60‐100 bpm


PRI: 0.12‐0.20s

QRS: <0.12s

Atrial Flutter

Regular; atrial rate 250‐350 bpm

P Wave: sawtooth

PRI: unable to determine

QRS: <0.12s

Junctional Tachycardia



QRS


QRS: <0.12s

Atrial Fibrillation

Grossly irregular >350 bpm <100:

controlled vs. >100: uncontrolled

P Wave: fibrillatory

PRI: unable to measure

QRS: <0.12s

Supraventricular Tachycardia

Regular rapid arrhythmia

P Waves: invisible

PRI: unable to measure

QRS: narrow

Paroxysmal Atrial Tachycardia

Random atrial tachycardia that

breaks to normal

Paroxysmal Supraventricular

Tachycardia

Normal then sudden random SVT burst

Obscure regular rhythm

No P, rates vary




P=P, P>QRS, QRS narrow/wide,

functioning impulse with

gatekeeper

P, wide/bizarre QRS

1° Heart Block

Delay true block; “toll” in

AV junction

Underlying rhythm/rate

P Wave: normal upright,

followed by QRS

PRI: ≥0.20s; constant across

strip; prolonged PRI

QRS: <0.12s

AV Block Algorithm

Does PRI change?

NO YES

/ \

Are QRS missing? Is R‐R regular?

/ \

NO NO

1°HB 2°HB T1

Wenckebach

YES YES

2°HB T2 3° Complete HB

Classical Mobitz II

Premature Ventricular Contraction

Underlying rhythm, rate; disrupted by

ectopic beat

P Wave: not preceded by P; dissociated

P may be seen near PVC

PRI: focus in ventricles none

QRS: wide and bizarre; ≥0.12s, T wave

in opposite direction from R wave

2° HB Type 1: Wenckebach

(Mobitz I)

2 consecutive long PRI then

drop in QRS after P

Irregular, slightly lower than

normal rate (vary)

P Waves: normal, upright;

not always followed by QRS

QRS: >0.12s

Ventricular Tachycardia

Regular, slightly irregular, 150‐250

bpm; >250 moves to flutter; usually

<150

P Wave: not preceded by P; dissociated

P may be seen near PVC

PRI: focus in ventricles none

QRS: wide and bizarre; ≥0.12s, T wave

in opposite direction from R wave

2° HB Type II: Classical (Mobitz

II)

Intermittent block,

pattern; count # of blocks

R‐R regular/irregular; P‐P

regular; bradycardia rate: ½

to 1/3 slower than normal

depending on block

PRI: constantly paired with

QRS; can be >0.20s

QRS: <0.12s

3° HB: Complete Heart Block

Atria & ventricle dissociation,

communication

Regular

P Waves: normal upright, P>QRS,

superimposed QRS

PRI: may not exist

Junctional Rate: 40‐60 narrow QRS

(<0.12s)

Vetricular Rate: 20‐40, wider QRS

(≥0.12s)

Ventricular Fibrillation

Chaotic with no discernable waves or

complexes

Irregular compared to regular V‐tach

Cannot determine rate

Coarse vs. fine

Treatment

o Defibrillate

o Epinephrine

o Atropine or amiodarone

o Defibrillate

o Vasopressin




Idioventricular Rhythm

Usually regular, can be unreliable due

to lower site; 20‐40 bpm, can drop

below 20 bpm

P Wave: none

PRI: none

QRS: wide and bizarre: ≥0.12s

Accelerated Idioventricular Rhythm

Regular, unreliable due to slower rate;

ventricular escape ≥40 bpm

P Wave: none

PRI: none

QRS: wide and bizarre: ≥0.12s

Agonal Rhythm

Terminal, lethal arrhythmia, especially

when it has stopped beating in a

reliable pattern

“Dying heart”

1‐2 beats of wide, bizarre QRS

Treat as asystole

Asystole

No electrical activity in at least 2 leads

“Straight” line

Pulseless Electrical Activity

Rhythms on the monitor, but patient

has no pulse

Treat the cause

Basic Arrhythmia Rules

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