Chapter08

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Chapter 8 : 

Chapter 8 Rhythms

Rhythms: Major Concepts : 

Rhythms: Major Concepts General: Is rhythm fast or slow? Bradycardia <60 BPM Tachycardia >100 BPM

Regular vs. Irregular Rhythms : 

Regular vs. Irregular Rhythms Is rhythm regular or irregular? If irregular, is it: Regularly irregular (some form of regularity to the pattern) Irregularly irregular (no pattern at all)

Irregularly Irregular Rhythms : 

Irregularly Irregular Rhythms Atrial fibrillation Wandering atrial pacemaker Multifocal atrial tachycardia

P Waves (1 of 2) : 

P Waves (1 of 2) Do you see any P waves? P waves indicate atrial or supraventricular component Are all P waves identical? Identical P waves are generated by same pacemaker site Should have identical PR intervals

P Waves (2 of 2) : 

P Waves (2 of 2) Are P waves not identical? Two possible causes: Additional pacemaker cell firing Another component of complex superimposed on P wave Does each QRS complex have a P wave? Abnormal number of P waves suggests AV nodal block Is the PR interval constant?

QRS complexes (1 of 2) : 

QRS complexes (1 of 2) Are P waves and QRS complexes associated with one another? If yes: Entire complex is a normal beat. Entire complex is a premature beat. Entire complex is a low-grade AV nodal block. Are QRS complexes narrow or wide? Narrow indicates impulses usually found in supraventricular rhythms. Wide indicates impulses transmitted by direct cell-to-cell contact.

QRS complexes (2 of 2) : 

QRS complexes (2 of 2) Are QRS complexes grouped or not grouped? Useful in determining: Presence of AV nodal block Recurrent premature complexes Are there any dropped beats? Dropped beats occur in: AV nodal blocks Sinus arrest

Rhythms: Summary : 

Rhythms: Summary Do P waves and QRS complexes follow a regular pattern (same intervals separating them)? or Are intervals different between some or all of the beats?

Individual Rhythms : 

Individual Rhythms Supraventricular rhythms Ventricular rhythms Heart blocks

Normal Sinus Rhythm (NSR) : 

Normal Sinus Rhythm (NSR) Rate: 60-100 BPM Regularity: Regular P wave: Present P:QRS ratio: 1:1 PR interval: Normal QRS width: Normal Grouping: None Dropped beats: None

Sinus Arrhythmia : 

Sinus Arrhythmia Rate: 60-100 BPM Regularity: Varies w/ respiration P wave: Normal P:QRS ratio: 1:1 PR interval: Normal QRS width: Normal Grouping: None Dropped beats: None

Sinus Bradycardia : 

Sinus Bradycardia Rate: <60 BPM Regularity: Regular P wave: Present P:QRS ratio: 1:1 PR interval: Normal to prolonged QRS width: Normal to prolonged Grouping: None Dropped beats: None

Sinus Tachycardia : 

Sinus Tachycardia Rate: >100 BPM Regularity: Regular P wave: Present P:QRS ratio: 1:1 PR interval: Normal to short QRS width: Normal to short Grouping: None Dropped beats: None

Sinus Pause/Arrest : 

Sinus Pause/Arrest Rate: Varies Regularity: Irregular P wave: Present except in areas of pause/arrest P:QRS ratio: 1:1 PR interval: Normal QRS width: Normal Grouping: None Dropped beats: Yes

Sinoatrial Block : 

Sinoatrial Block Rate: Varies Regularity: Irregular P wave: Present except in areas of dropped beats P:QRS ratio: 1:1 PR interval: Normal QRS width: Normal Grouping: None Dropped beats: Yes

Atrial Premature Contraction (APC) : 

Atrial Premature Contraction (APC) Rate: Depends on underlying sinus rate Regularity: Irregular P wave: Present; in APC, may be different shape P:QRS ratio: 1:1 PR interval: Varies in APC QRS width: Normal Grouping: Sometimes Dropped beats: None

Ectopic Atrial Tachycardia : 

Ectopic Atrial Tachycardia Rate: 100-180 BPM Regularity: Regular P wave: Morphology of ectopic focus is different P:QRS ratio: 1:1 PR interval: Ectopic focus has different interval QRS width: Normal, but aberrant at times Grouping: None Dropped beats: None

Wandering Atrial Pacemaker (WAP) : 

Wandering Atrial Pacemaker (WAP) Rate: 100 BPM Regularity: Irregularly irregular P wave: At least 3 different morphologies P:QRS ratio: 1:1 PR interval: Variable depending on focus QRS width: Normal Grouping: None Dropped beats: None

Multifocal Atrial Tachycardia (MAT) : 

Multifocal Atrial Tachycardia (MAT) Rate: >100 BPM Regularity: Irregularly irregular P wave: At least 3 different morphologies P:QRS ratio: 1:1 PR interval: Variable QRS width: Normal Grouping: None Dropped beats: None

Atrial Flutter : 

Atrial Flutter Rate: Atrial commonly 250–350 BPM, ventricular commonly 125–175 BPM Regularity: Usually regular P wave: Saw toothed, “F waves” P:QRS ratio: Variable, most commonly 2:1 PR interval: Variable QRS width: Normal Grouping: None Dropped beats: None

Atrial Fibrillation : 

Atrial Fibrillation Rate: Variable, ventricular response can be fast or slow Regularity: Irregularly irregular P wave: None; chaotic atrial activity P:QRS ratio: None PR interval: None QRS width: Normal Grouping: None Dropped beats: None

Junctional Premature Contraction (JPC) : 

Junctional Premature Contraction (JPC) Rate: Depends on underlying rhythm Regularity: Irregular P wave: Variable (none, antegrade, or retrograde) P:QRS ratio: None, or 1:1 if retrograde PR interval: None, short, or retrograde QRS width: Normal Grouping: Usually none Dropped beats: None

Junctional Escape Beat : 

Junctional Escape Beat Rate: Depends on underlying rhythm Regularity: Irregular P wave: Variable (none, antegrade, or retrograde) P:QRS ratio: None; or 1:1 if antegrade or retrograde PR interval: None, short, or retrograde QRS width: Normal Grouping: None Dropped beats: Yes

Junctional Rhythm : 

Junctional Rhythm Rate: 40–60 BPM Regularity: Regular P wave: Variable (none, antegrade, or retrograde) P:QRS ratio: None; or 1:1 if antegrade or retrograde PR interval: None, short, or retrograde QRS width: Normal Grouping: None Dropped beats: None

Accelerated Junctional Rhythm : 

Accelerated Junctional Rhythm Rate: 60–100 BPM Regularity: Regular P wave: Variable (none, antegrade, or retrograde) P:QRS ratio: None; or 1:1 if antegrade or retrograde PR interval: None, short, or retrograde QRS width: Normal Grouping: None Dropped beats: None

Ventricular Premature Contraction (VPC) : 

Ventricular Premature Contraction (VPC) Rate: Depends on underlying rhythm Regularity: Irregular P wave: Not present on VPC P:QRS ratio: No P waves on VPC PR interval: None QRS width: Wide (0.12 sec), bizarre appearance Grouping: Usually not present Dropped beats: None

Ventricular Escape Beat : 

Ventricular Escape Beat Rate: Depends on underlying rhythm Regularity: Irregular P wave: None in VPC P:QRS ratio: None in VPC PR interval: None QRS width: Wide (0.12 sec), bizarre appearance Grouping: None Dropped beats: None

Idioventricular Rhythm : 

Idioventricular Rhythm Rate: 20–40 BPM Regularity: Regular P wave: None P:QRS ratio: None PR interval: None QRS width: Wide (≥0.12 sec), bizarre appearance Grouping: None Dropped beats: None

Accelerated Idioventricular Rhythm : 

Accelerated Idioventricular Rhythm Rate: 40–100 BPM Regularity: Regular P wave: None P:QRS ratio: None PR interval: None QRS width: Wide (≥0.12 sec), bizarre appearance Grouping: None Dropped beats: None

Ventricular Tachycardia (VTach) : 

Ventricular Tachycardia (VTach) Rate: 100–200 BPM Regularity: Regular P wave: Dissociated atrial rate P:QRS ratio: Variable PR interval: None QRS width: Wide, bizarre Grouping: None Dropped beats: None

VTach: Fusion Beats : 

VTach: Fusion Beats A hybrid complex with some features of both areas of the ventricle being stimulated simultaneously Has morphology between abnormal ventricular beat and normal QRS complex Caused by two pacemakers: SA node Ventricular pacer

VTach: Capture Beats : 

VTach: Capture Beats Occur in the middle of VTach Caused by chance timing of sinus beat to “capture” or transmit through AV node Depolarize ventricles through normal conduction system

VTach Indicators : 

VTach Indicators Fusion and capture beats Brugada’s sign: In VTach, interval from R wave to bottom of S wave is ≥0.10 sec Josephson’s sign: Small notching at low point of S wave Total QRS width of ≥0.16 sec Complex negativity of all precordial leads

Brugada’s and Josephson’s Signs : 

Brugada’s and Josephson’s Signs

Torsade de Pointes : 

Torsade de Pointes Rate: 200–250 BPM Regularity: Irregular P wave: None P:QRS ratio: None PR interval: None QRS width: Variable Grouping: Variable sinusoidal pattern Dropped beats: None

Ventricular Flutter : 

Ventricular Flutter Rate: 200–300 BPM Regularity: Regular P wave: None P:QRS ratio: None PR interval: None QRS width: Wide, bizarre Grouping: None Dropped beats: None

Ventricular Fibrillation (VFib) : 

Ventricular Fibrillation (VFib) Rate: Indeterminate Regularity: Chaotic rhythm P wave: None P:QRS ratio: None PR interval: None QRS width: None Grouping: None Dropped beats: No beats at all

First-Degree Heart Block : 

First-Degree Heart Block Rate: Depends on underlying rhythm Regularity: Regular P wave: Normal P:QRS ratio: 1:1 PR interval: Prolonged >0.20 sec QRS width: Normal Grouping: None Dropped beats: None

Mobitz I Second-Degree Heart Block : 

Mobitz I Second-Degree Heart Block Rate: Depends on underlying rhythm Regularity: Regularly irregular P wave: Present P:QRS ratio: Variable; 2:1, 3:2, 4:3, 5:4, etc. PR interval: Variable QRS width: Normal Grouping: Present and variable Dropped beats: Yes

Mobitz II Second-Degree Heart Block : 

Mobitz II Second-Degree Heart Block Rate: Depends on underlying rhythm Regularity: Regularly irregular P wave: Normal P:QRS ratio: X:X–1 PR interval: Normal QRS width: Normal Grouping: Present and variable Dropped beats: Yes

Third-Degree Heart Block : 

Third-Degree Heart Block Rate: Separate rates for underlying (sinus) rhythm and escape rhythm Regularity: Regular, but P rate and QRS rates are different P wave: Present P:QRS ratio: Variable PR interval: Variable, no pattern QRS width: Normal or wide Grouping: None Dropped beats: None Note: If there are as many P waves as QRS waves but they are dissociated, it is AV dissociation, NOT third-degree heart block.

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