Rhythm Recognition

Objectives
Understand the 6-stage system to rhythm recognition

Identify the parts of the conduction system that correspond with
each rhythm strip

Discuss key points, causes and the treatment for each rhythm


The 6-Stage System
1. Is there any electrical activity?

2. What is the ventricular (QRS) rate?

3. Is the QRS rhythm regular or irregular?

4. Is the QRS complex width normal or prolonged?

5. Is atrial activity present?

6. Is atrial activity related to ventricular activity and, if so, how?
Normal Sinus Rhythm
Key points:

There is electrical activity
The ventricular rate is normal (60-100bpm)
The QRS rhythm is regular
The QRS width is normal (0.12 second or 3 small
squares)
Atrial activity is present
The P wave has a normal relationship with the
QRS complex, the P-R interval is between 0.12
seconds (3 small squares) and 0.20 seconds (5
small squares)




Sinus Bradycardia
Key points:

There is electrical activity
The ventricular rate is slow (< 60 bpm)
The QRS rhythm is regular
The QRS width is normal (0.12 second or 3 small
squares)
Atrial activity is present
The P wave has a normal relationship with the
QRS complex, the P-R interval is between 0.12
seconds (3 small squares) and 0.20 seconds (5
small squares)
This rhythm may be normal in the athletic
person

Causes:

Relaxation, increased vagal tone, raised ICP,
hypoglycaemia

Sinus Tachycardia
Key points:

There is electrical activity
The ventricular rate is fast (> 100 bpm)
The QRS rhythm is regular
The QRS width is normal (0.12 second or 3 small
squares)
Atrial activity is present
The P wave has a normal relationship with the
QRS complex, the P-R interval is between 0.12
seconds (3 small squares) and 0.20 seconds (5
small squares)

Causes:

Exercise, stress, anxiety, illness, dehydration,
sepsis, pain


Pulseless Ventricular Tachycardia
Key points:

There is electrical activity
The ventricular rate is fast (> 200 - 300 bpm)
The QRS rhythm is regular
The QRS width is broad with a constant QRS
morphology
Atrial activity is not present
No pulse

Causes:

Systolic BP < 90 mmHg
HR > 150 bpm
ACS (chest pain)
Heart failure (structural heart disease, impaired
left ventricular function, extreme left ventricular
hypertrophy, aortic stenosis)

Hypoxia, Hypovolaemia,
Hypo/hyperkalaemia/metabolic, Hypothermia,
Tension pneumothorax, Tamponade (cardiac),
Toxins, Thromboembolic event


Ventricular Fibrillation
Key points:

All of the hearts natural pacemakers are firing at
the same time
Uncoordinated electrical activity
No recognisable QRS complexes
Bizarre irregular waveform
Random frequency and amplitude (course or
fine)
No pulse

Causes:

Hypoxia, Hypovolaemia,
Hypo/hyperkalaemia/metabolic, Hypothermia,
Tension pneumothorax, Tamponade (cardiac),
Toxins, Thromboembolic event


Pulseless Electrical Activity
Key points:

There is electrical activity
The ventricular rate may be fast or slow
The QRS rhythm may be regular or irregular
The QRS width may be narrow or broad
Atrial activity may or may not be present
Clinical absence of cardiac output despite
electrical activity
There are clinical features of cardiac arrest
No pulse

Causes:

Hypoxia, Hypovolaemia,
Hypo/hyperkalaemia/metabolic, Hypothermia,
Tension pneumothorax, Tamponade (cardiac),
Toxins, Thromboembolic event


Asystole
Key points:

There is no electrical activity
Atrial activity may persist (P-wave asystole)
This rhythm is not a straight line
No pulse

Causes:

Systolic BP < 90 mmHg
HR < 40 bpm
Ventricular arrhythmias compromising BP
Heart failure

Hypoxia, Hypovolaemia,
Hypo/hyperkalaemia/metabolic, Hypothermia,
Tension pneumothorax, Tamponade (cardiac),
Toxins, Thromboembolic event


Supraventricular Tachycardia
Key points:

There is electrical activity
The ventricular rate is fast (> 150 bpm)
The QRS rhythm is regular
The QRS width is narrow (< 0.12 second or 3
small squares)
Atrial activity is present
The P wave has a normal relationship with the
QRS complex, the P-R interval is between 0.12
seconds (3 small squares) and 0.20 seconds (5
small squares)

Causes:

Systolic BP < 90 mmHg
HR > 150 bpm
Chest pain
Heart failure (structural heart disease, impaired
left ventricular function, extreme left ventricular
hypertrophy, aortic stenosis)



Atrial Fibrillation
Key points:

There is electrical activity
The ventricular rate may be normal (60-100 bpm)
or fast (> 100 bpm)
The QRS rhythm is irregular
The QRS width may alternate between be narrow
and broad
Atrial activity may or may not be present
Atrial electrical activity is uncoordinated
During a sustained tachycardia, atrial activity is
usually not visible

Causes:

Drugs
Heart disease
Virus



Atrial Flutter
Key points:

There is electrical activity
The ventricular rate is fast (> 100-300 bpm)
The QRS rhythm may be regular or irregular
The QRS width is narrow
Atrial activity is present
Atrial activity is seen as flutter waves with a saw
tooth appearance
Atrial activity usually forms a repetitive cycle
When every 2
nd
, 3
rd
or 4
th
P wave is conducted,
this is referred to as 2:1, 3:1 and 4:1 AV block,
and so on

Causes:

Drugs
Heart disease

First Degree Atrioventricular Block
Key points:

There is electrical activity
The ventricular rate is normal (60-100bpm)
The QRS rhythm is regular
The QRS width is normal (0.12 seconds or 3
small squares)
Atrial activity is present
The P-R interval is prolonged (> 0.20 seconds or
5 small squares)
The block is at the level of the AV junction
First degree AV block rarely causes symptoms

Causes:

Drugs
Heart disease
Delay with conduction through the AV junction


Second Degree Atrioventricular Block
(Mbitz Type I or Wenckebach AV Block)
Key points:

There is electrical activity
The ventricular rate is normal (60-100bpm)
The QRS rhythm is irregular
The QRS width is normal (0.12 seconds or 3
small squares)
Atrial activity is present
The P-R interval shows a progressive
prolongation after each successive P wave until
a P wave occurs without a resulting QRS
complex.
The block is at the level of the AV junction
Second degree AV block (Mbitz Type I or
Wenckebach AV Block) rarely causes symptoms

Causes:

Heart disease
Delay with conduction through the AV junction


Second Degree Atrioventricular Block
(Mbitz Type II AV Block)
Key points:

There is electrical activity
The ventricular rate may or may not be normal
The QRS rhythm may or may not be regular
The QRS width is normal (0.12 seconds or 3
small squares)
Atrial activity is present
Some of the P waves are not followed by QRS
complexes
This may occur randomly or there may be a
cyclic relationship between the P waves and the
conducted QRS complexes
The block is at the level of the bundle branches
2:1 AV block is present if the QRS follows every
other P wave
When every 3
rd
, 4
th
or 5
th
P wave is conducted,
this is referred to as 3:1, 4:1 and 5:1 AV block,
and so on
This rhythm occasionally results in P-wave
asystole

Causes:

Heart disease
Delay with conduction through the AV junction



Third Degree (Complete)
Atrioventricular Block
Key points:

There is electrical activity
The ventricular rate may or may not be normal
The QRS rhythm may or may not be regular
The QRS width may be narrow or broad
depending on the ventricular rate
The QRS complexes are usually broad when the
ventricular rate is less than 30-40bpm
Atrial activity is usually present
There is no relationship between the P waves
and the QRS complexes
This rhythm is likely to stop abruptly, resulting in
asystole

Causes:

Heart disease



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Summary
Understand the 6-stage system to rhythm recognition

Correlate what is happening within the conduction system with what is
seen on the rhythm strip

Discuss key points, causes and the treatment for each presenting
rhythm