Cardiac Rhythms

Normal Sinus Rhythm (NSR): Normal conduction, Normal CO

Interpretation: P wave, QRS complex, T wave present per each conducted beat
R=R
Rate- 60-100 bpm
PR interval 0.12-0.20 seconds
QRS 0.04-0.10seconds

Sinus Bradycardia (SB): Decreased rate of atrial depolarization, slowing SA node conduction

Interpretation: P wave, QRS complex, T wave present per each conducted beat
R=R
Rate <60 (usually 40-59 bpm)
PR interval 0.12-0.20 seconds
QRS 0.04-0.10seconds

Sinus Tachycardia (ST): Increased rate of discharge from the SA node, increasing HR

Interpretation: P wave, QRS complex, T wave present per each conducted beat
R=R
Rate >100 (not usually <150 bpm)
PR interval 0.12-0.20 seconds
QRS 0.04-0.10seconds
Sinus Dysrhythmia (Sinus Arrhythmia): Variation of NSR; when measured R-R off (>0.12)

Interpretation: P wave, QRS complex, T wave present per each conducted beat
RR (>0.12 second difference)
Rate 60-100 bpm (may be <60 or >100 bpm)
PR interval 0.12-0.20 seconds
QRS 0.04-0.10seconds

Premature Ventricular Contractions (PVCs): Premature impulse from either ventricle before
SA node fire and atrial conduction. Decreased or incomplete atrial filling.

ST and T wave negative deflection

Interpretation: no P wave, wide, bizarre (notched) QRS complex, ST segment and T wave
opposite direction of QRS complex
RR between sinus beat and PVC; R=R between sinus beats
Rate variable depending on underlying rhythm
QRS >0.12 seconds (of PVC complex

Runs of PVCs (Salvos or runs of V tach): May be a couplet (2 or more PVCs after one
another), Bigeminal (1 PVC after each sinus beat), Trigeminal (1 PVC for every 2 sinus beats),
Triplets (>3 in a row), Salvos (or Runs of VT) >4 PVCs in a row.

Salvo of PVCs
 Trigeminal and Bigeminal PVCs

Couplet of PVCs

Uniform (Unifocal) or Multiform (Multifocal) PVCs:

Multifocal and Unifocal PVCs

QRS complexes of PVCs are different morphologies (multiform), meaning they are firing from
different origins (foci) of the ventricles; or QRS complexes on the strip are all the same
(uniform); meaning they are firing from the same origin (foci) of the ventricle.

Premature Atrial Contractions (PACs): Atria fire early before the next conducted beat

peaked P wave before QRS complex

Interpretation: Morphology of P wave different from sinus P wave; early, upright, peaked,
notched, slurred, or wide
RR between sinus beat and PAC; R=R between sinus beats
Rate variable depending on underlying rhythm
PR interval 0.12-0.20 seconds (but different from sinus beat)
QRS 0.04-0.10seconds
Atrial Fibrillation (AF, A-Fib): Atria firing at rapid rate with variable ventricular conduction
beats with chaotic depolarization of random atrial fibers. Decreased CO because of short
ventricular filling from atria.

Interpretation: Atria do not contract as a whole (they are quivering); no uniform

depolarization= no defined P wave. May be course or fine A-fib
RR
Rate variable- (ventricular rate) usually between 160-180 bpm (untreated), 60-100 bpm (treated)
PR interval unidentifiable, unable to measure
QRS 0.04-0.10seconds (usually normal)

Atrial Flutter (AF, A-Flutter): Atrial firing in dependently from ventricles as in A-Fib.

3:1 conduction (atria to ventricles) 2:1 conduction

Interpretation: P and T waves merge to form sawtooth pattern between QRS complexes. May
be variant conduction between flutter waves and QRS complexes (1:1, 2:1, 3:1).
RR ( w/ variant conduction) or R=R (with uniform conduction)
Rate variable- (ventricular rate) usually 150 bpm
PR interval unidentifiable, unable to measure; P waves replaced by sawtooth P-T wave formation
QRS 0.04-0.10seconds (usually normal)

First Degree Atrioventricular Block (1st degree AVB): Considered a delay in conduction at
the AV junction slowing conduction time to ventricles
PRI >0.20 seconds

Interpretation: Delay in conduction is constant with each beat, PR interval longer than normal.
R=R
Rate variable depending on underlying rhythm
PR interval >0.20-0.40 seconds (constant/consistent)
QRS 0.04-0.10seconds (usually normal)
Second Degree AVB Type I (Wenckebach or Mobitz I): Conduction blocked at the AV node
(mostly); considered an incomplete block because not all atrial impulses reach ventricles.
Often d/t parasympathetic tone or drug effect.

Progressive PRI then single P wave with a dropped QRS complex

Interpretation: Progressive prolongation of the PR interval followed by a dropped (or blocked

by the AV node) QRS complex. Usually only a single impulse is blocked then the cycle repeats.
Associated phrase: Further, further, further, dropmust be a Wenckeback.
RR
Rate- ventricular rate < atrial rate
PR interval prolongs until 1 P wave exists without a QRS complex
QRS 0.04-0.10seconds (usually normal)

Second Degree AVB Type II (Mobitz II): Conduction blocked at the Bundle of His or bundle
braches (most common); considered an incomplete block as well. Associated with organic
lesions along the conduction pathway, and may develop into complete HB.
Constant PRI with associated QRS complexes, and non-conducted P waves

Interpretation: Blocks in the bundle braches cause a complete block in one branch with an
intermittent block in conduction down the opposite bundle branch (QRS may be wide). In the
bundle of HIS the QRS will be normal because ventricular conduction is not disturbed.
RR
Rate- ventricular rate < atrial rate
PR interval remains the same, with intermittent non-conducted P waves
QRS 0.04-0.10seconds (usually normal), but may be >0.10 seconds
Third Degree AVB (Complete HB): No impulses travel between the atria and ventricles. AV
junction takes over as ventricular pacemaker and atria fire on their own time with slowing
ventricular tempo. Patient may die if AV junction does not kick in, or stops conduction.
Multiple P waves dissociated from QRS complexes

Interpretation: Lack of relationship between P waves and QRS complexes; each maintains own
rhythm without regard for the other (atria and ventricles). AV junction rhythm will have normal
QRS, below AVJ will have wide QRS. Causes: Parasympathetic tone, AMI, Drug toxicity).
R=R (usually)
Rate- ventricular rate < atrial rate ( junctional rate 40-60 bpm, ventricle rate 20-40 bpm)
PR interval varies; P too close or far to be associated with QRS
QRS 0.04-0.10seconds (usually normal), but may be >0.10 seconds

Ventricular Tachycardia (V-Tach, VT): >3 ventricular complexes occurring in succession

Narrow VT

Wide VT with P waves

Interpretation: Ventricles generating in a rapid rhythm, usually regular, and can be sustained
(non self-terminating) or non-sustained (self-terminating). If there is a abrupt onset and
termination it is a run of VT or Salvo of VT. ST-T wave are opposite direction of QRS complex.
R=R (usually)
Rate >100 bpm, but <220 bpm
PR interval not detectable b/c of no P waves or P waves not associated with QRS complexes
QRS wide and bizarre; >0.12 seconds

*Can have pulseless VT or VT with a pulse*: Pulseless needs immediate defibrillation

Ventricular Fibrillation (V-Fib, VF): Chaotic depolarization and repolarization of the
ventricles; NO CO and NO pulseyour patient is DEAD!!! You must defibrillate
immediately!!

Course VF

Fine VF

Interpretation: Normal looking waveform(s) are absent, No definable P, QRS, T waves. Course
or Fine VF. Course VF suggests recent onset- better outcomes with immediate defibrillation.
RR and chaotic looking
Rate undetectable
PR interval not detectable
QRS not detectable

Torsade de Pointes: Typically initiated by a short-long-short interval. A ventricle extrasystole

(first beat: short) is followed by a compensatory pause. The following beat (second beat: long)
has a longer QT interval.

Interpretation: If the next beat follows shortly thereafter, there is a good chance that this third
beat falls within the QT interval, resulting in the R on T phenomenon and subsequent Torsades
de pointes. During Torsades de pointes the ventricles depolarize in a circular fashion resulting in
QRS complexes with a continuously turning heart axis around the baseline (flipping axes).

Treatment: Withdrawal of any offending drugs and correction of electrolyte abnormalities;

magnesium IV will help convert
Ventricular Standstill (Asystole, Ventricular Asystole, or Flatline): Total absence of
ventricular activity. No ventricle depolarization or contraction. May be primary reason for arrest
or follow VF arrest. Your patient is DEAD!!

Interpretation: May be line with no electrical activity or with P waves.

R-R undetectable
Rate if P waves, ventricular rate= 0
PR not detectable
QRS not detectable (total absence of ventricular activity)

Treatment: electrical activity needs to be stimulated first!! Epinephrine, transcutaneous pacing

Paced Rhythms (Atrial, Ventricular, AV pacing): Present when patient has a permanent,
temporary pacer or is being transcutaneous paced.
Junctional Rhythms: Originates in the AV node; SA fails to fire or conduction has been
blocked

Interpretation: P waves are inverted or occur behind QRS complex.

R=R
Rate= 40-60 bpm
PR may be shorter than usual
QRS should be 0.04-0.10 sec

Treatment: if symptomatic treat with Atropine

Accelerated Junctional and Junctional Tachycardia: Origin same as junctional rhythm; rate
faster

Interpretation: P waves are inverted or occur behind QRS complex.

R=R
Rate= accelerated 60-100 bpm; tachycardia= >100 bpm
PR= usually not present
QRS should be 0.04-0.10 sec

Treatment: if accelerated junctional or tachycardia caused by digoxin= HOLD dig!! Beta

blockers, Ca channel blockers, and Amiodarone used for rate control NOT caused by dig toxicity
Idioventricular Rhythm (IVR): SA and AV node impulses fail; impulses fired from ventricles

Interpretation: P waves absent or unrelated to QRS.

R=R
Rate= 20-40 bpm
PR= usually not present
QRS= >0.12 sec

Treatment: if symptomatic give atropine, transcutaneous pacing

Accelerated Idioventricular Rhythm (AIVR): Same as IV rhythm but rate is accelerated

Interpretation: P waves absent or unrelated to QRS.

R=R
Rate= 40-100 bpm
PR= usually not present
QRS= >0.12 sec

Treatment: if symptomatic give atropine, transcutaneous pacing; DO NOT give medications to

block ventricular arrhythmias!! This is the system providing conduction.
Paroxysmal Supraventricular Tachycardia (PSVT): Can originate anywhere above Bundle of
His; usually initiated by PACs. AVB may be present as well as underlying atrial arrhythmias.
Can occur in Wolff- Parkinson-White syndrome (WPW)

Interpretation: P waves absent on strip but buried in QRS complexes.

R=R
Rate= >150 bpm
PR= usually not present
QRS= < 0.12 sec

Treatment: Try vagal maneuvers first (valsalva, coughing, suctioning), then administer
adenosine. If medication and vagal maneuvers unsuccessful= cardioversion needed. IF WPW
syndrome present; treat as would for VT if unstable.

Pulseless Electrical Activity (PEA): electrical tracing will be present and may include ALL
elements of conduction but ventricles are still and persona has NO PULSE!!

Interpretation: Will be dependent on conduction deficit; may look like NSR but most often will
be ventricular-based
R-R depends on rhythm conducted
Rate= 0you have no pulse but you may be able to count rate on strip
PR= depends on conducted rhythm
QRS= depends on conducted rhythm

Treatment: CPR and epinephrine. Atropine if ventricular rate is slow. Treat underlying
causehypoxia, metabolic acidosis, hypothermia, hypo/hyperkalemia, drug overdose, PE.