Sinus Rhythm (SR) Sinus Rhythm (SR) Criteria

Rhythm of normally functioning system
Current follows normal pathway, without
interference.
Rhythm - interval between two P and two R
waves occurs in consistent pattern
Rate - atria and ventricular rates - 60 - 100
P-wave configurations
„ Uniform shape
„ Usually upright deflection
„ P-wave appears prior to every QRS complex.

Chapter 5 1 Chapter 5 2

Sinus Rhythm (SR) Criteria SR – How Patient Is Affected

PR interval Rhythm is typical of patient with normal
„ Consistent cardiac output.
„ Between .12 and .20 seconds Patient symptoms
QRS duration „ Alert
„ Consistent „ Breathing normally
„ Between .06 and .10 seconds „ No chest pain or pressure

„ Stable blood pressure

Chapter 5 3 Chapter 5 4

SR – How Patient Is Affected (Cont’d) Sinus Bradycardia (SB)

If patient has returned to SR from another
dysrhythmia
„ Check for low cardiac output.
„ If symptoms of low cardiac output are present,
inform a licensed practitioner.
Rhythm less than 60 beats per minute
All other rhythm characteristics same as
Sinus Rhythm (SR)

Chapter 5 5 Chapter 5 6

1
Sinus Bradycardia (SB) - Criteria Sinus Bradycardia (SB) - Criteria
Rhythm - interval between two P and two R PR interval
waves occurs in consistent pattern „ Consistent
Rate - atria and ventricular rates - 40 – 60 „ Between .12 and .20 seconds
P-wave configuration QRS duration
„ Uniform shape „ Consistent
„ Usually upright deflection „ Between .06 and .10 seconds
„ P-wave appears prior to every QRS complex

Chapter 5 7 Chapter 5 8

SB - How Patient Is Affected Sinus Tachycardia (ST)

Patient may or may not exhibit signs of low Rhythm more than 100 beats per minute.
cardiac output. All other rhythm characteristics same as SR.
If symptoms of low cardiac output are
present, inform a licensed practitioner.
Rhythm may require drugs or pacemaker.

Chapter 5 9 Chapter 5 10

Sinus Tachycardia (ST) - Criteria Sinus Tachycardia (ST) - Criteria

Rhythm - interval between two P and two R PR interval
waves occurs in consistent pattern „ Consistent
Rate - atria and ventricular rates - 100 – 150 „ Between .12 and .20 seconds
P-wave configuration QRS duration
„ Uniform shape „ Consistent
„ Usually upright deflection „ Between .06 and .10 seconds
„ P-wave appears prior to every QRS complex.

Chapter 5 11 Chapter 5 12

2
ST – How Patient Is Affected
Increased heart rate could be normal
response to recent exercise.
Low cardiac output can cause ST
„ Patient may complain of heart
fluttering/palpitations.
Chapter 5
Sinus Arrhythmia (SA)
Rhythm within normal limits.
Rhythm is irregular, caused by pressure on the
heart from respiratory cycle and variations of
vagal tone.
Chapter 5
Sinus Arrhythmia (SA) - Criteria
PR interval
„ Consistent
„ Between .12 and .20 seconds
QRS duration
„ Consistent
„ Between .06 and .10 seconds
Chapter 5
ST – How Patient Is Affected
ST may be life threatening in patients with
recent myocardial infarctions.
If symptoms of low cardiac output are
present, inform a licensed practitioner
immediately.
„ Medication may be necessary.
13 Chapter 5 14
Sinus Arrhythmia (SA) - Criteria
Rhythm - interval between two P and two R
waves is irregular
Rate - atria and ventricular rates - 60 – 100
P-wave configuration
„ Uniform shape
„ Usually upright deflection
„ P-wave appears prior to every QRS complex.
15 Chapter 5 16
SA – How Patient Is Affected
Patient usually shows no visible signs.
Severe cases may slow heart rate to 40’s,
causing dizziness or palpitations.
Notify physician or licensed practitioner.
Place copy of rhythm strip in patient’s
record.
17 Chapter 5 18
3
Sinus Arrest
Condition where SA node stops firing,
causing pause in electrical activity.
During the pause, atrial and ventricular
contraction do not occur.
Sinus Arrest - Criteria
Rhythm - interval between two P and two R waves
is irregular
Rate - atria and ventricular rates will be the same,
but rate will vary depending on amount of
electrical activity in SA node
P-wave configuration
„ Uniform shape
„ Usually upright deflection
„ P-wave appears prior to every QRS complex.

Chapter 5 19 Chapter 5 20

Sinus Arrest - Criteria Sinus Arrest - Criteria

PR interval Length of pause
„ Consistent „ Measure the R-R interval around the pause.
„ Between .12 and .20 seconds „ Multiply number of boxes by .04.
QRS duration „ Frequency of pauses should be noted.

„ Consistent
„ Between .06 and .10 seconds

Chapter 5 21 Chapter 5 22

Sinus Arrest – How Patient Is Premature Atrial Contractions

Affected
Seriousness depends on length of pause.
Frequent pauses of two seconds will cause
symptoms of decreased cardiac output.
Notify licensed practitioner.
Immediate treatment required.
(PAC)
Electrical impulses originate in the atria and
initiate early impulse which disrupts regular
rhythm.

Chapter 5 23 Chapter 5 24

4
Premature Atrial Contractions Premature Atrial Contractions
(PAC) - Criteria (PAC) - Criteria
Rhythm - regularity between P-P and R-R P-wave configuration
intervals is constant, with exception of „ Uniform shape, except for early beat
occasional early complex „ Early beat may be flattened, notched, biphasic
or otherwise unusual.
Rate - atria and ventricles usually 60 - 100
„ Early P-wave may be hidden within T-wave.
depending on frequency of PAC’s
PR interval
„ Between .12 and .20 seconds
„ Early beat will have different PR measurements
but within normal limits.
Chapter 5 25 Chapter 5 26

Premature Atrial Contractions

(PAC) - Criteria PAC – How Patient Is Affected
QRS duration Patient may experience the symptoms of
„ Between .06 and .10 seconds low cardiac output.
Rhythm strip must be labeled with type of Notify licensed practitioner if symptoms of
rhythm and PAC. low cardiac output are present.

Chapter 5 27 Chapter 5 28

Atrial Flutter (A Flutter) Atrial Flutter (A Flutter)

Occurs when rapid impulse originates in
atrial tissue
Ectopic focus may originate from ischemic
areas or from reentry pathway.
Reentry pathways provide faster routes for
impulses.
May lead to more serious condition (atrial
dysrhythmia) if not treated

Chapter 5 29 Chapter 5 30

5
Atrial Flutter (A Flutter) -Criteria
Rhythm
„ P-P interval or flutter-to-flutter waves will be
regular and stay constant throughout rhythm.
„ R-R interval usually irregular, but may,
occasionally be regular in the pattern.
Rate - 250 - 300 beats per minute
Atrial Flutter (A Flutter) -Criteria
P-wave configuration
„ P-wave not seen, only flutter waves present.
„ Flutter waves resemble saw-tooth or picket
fence and are best seen in leads II, III and AVF.
PR interval - not identifiable
QRS interval - .06 - .10 seconds

Chapter 5 31 Chapter 5 32

A Flutter – How Patient Is Affected A Flutter – How Patient Is Affected

Loss of atrial kick reduces cardiac output by
10 - 30%.
Patients with increased heart rate will
demonstrate signs of low cardiac output.
Notify licensed practitioner when atrial
flutter occurs.
Treatment plan may include oxygen.
ECG strips are mounted and saved in
patient’s record.

Chapter 5 33 Chapter 5 34

Atrial Fibrillation (A Fib.) Atrial Fibrillation (A Fib.)

Occurs when electrical impulses come from
areas of reentry pathways or multiple
ectopic foci.
Electrical impulse results in depolarization
of small groups of cells, versus whole atria.
Multiple atrial activity recorded as chaotic
wave.

Chapter 5 35 Chapter 5 36

6
A Fib. - Criteria A Fib. - Criteria
Rhythm P-wave configuration
„ P-P interval not determinable. „ Cannot be identified
„ R-R interval is irregular. „ Chaotic electrical activity or f waves may be
Rate seen.
„ Atrial rate 375 - 700 beats per minute. PR interval - cannot be identified
„ Ventricular rate, prior to medication is 160 - QRS duration - .06 - .10 seconds, irregular
180.

Chapter 5 37 Chapter 5 38

A Fib. – How Patient Is Affected A Fib. – How Patient Is Affected

Patient exhibits signs of decreased cardiac Blood collecting in atria can clot or form
output. thrombus which increases risk of embolism.
When heart rate is controlled, patient may Report complications or vital sign changes
be able to tolerate loss of atrial kick. to licensed practitioner.

Chapter 5 39 Chapter 5 40

Rhythms Originating from the

Atrial-Junction Node
AV node cells have automaticity and can
function as pacemaker in the event the SA
node has been injured.
AV node rate is 40 - 60 beats per minute.
Junctional Rhythm (JR)
Originates at AV junctional tissue
Produces retrograde depolarization of atrial
tissue
Stimulates depolarization of ventricles

Chapter 5 41 Chapter 5 42

7
Junctional Rhythm (JR) - Criteria Junctional Rhythm (JR) - Criteria
Rhythm P wave configuration
„ P-P and R-R intervals are regular and have „ Usually inverted
similar intervals. „ May follow, precede, be within QRS complex,
„ P-P interval may be difficult to determine due or not be visible
to location of P wave. PR interval - if before the QRS complex,
Rate - if P wave is identifiable, rate will be will be less than .12 seconds and be
40 - 60 beats per minute. constant, otherwise cannot be determined
QRS duration - .06 - .10 seconds
Chapter 5 43 Chapter 5 44

JR – How Patient Is Affected Supraventricular Dysrhythmias (SVT)

Slower heart rate can lead to low cardiac Rapid heart beat makes identification of
output, leading to hypotension, confusion, origin difficult.
or disorientation.
Report JR to a licensed practitioner for
treatment.

Chapter 5 45 Chapter 5 46

Supraventricular Dysrhythmias Supraventricular Dysrhythmias

(SVT) - Criteria (SVT) - Criteria
Rhythm P wave configuration
„ R-R usually regular „ Usually not identifiable at this heart rate, since
„ If identifiable, P waves usually regular P wave may lie inside T wave
„ P wave may occur before, during or after QRS
Rate
complex.
„ Ventricular rate is 150 - 350 beats per minute.
„ Atrial rate is difficult to determine.
PR interval - usually unable to determine
QRS duration - .06 - .10 seconds

Chapter 5 47 Chapter 5 48

8
SVT – How Patient Is Affected
Patient may be in stable or unstable
condition.
Observe patient for low cardiac output.
Notify licensed practitioner and begin
treatment as early as possible.
Chapter 5
First Degree AV Block
Delay in electrical conduction from SA
node to AV node
Electrical stimulus is prevented from
traveling to ventricular conduction system.
Chapter 5
First Degree AV Block - Criteria
PR interval - greater than .20 seconds
QRS duration - normal .06 - .10 seconds
Chapter 5
Heart Block Rhythms
Occur when electrical activity has difficulty
traveling along normal conduction pathway
Ventricular depolarization is absent or delayed.
1st Degree Heart Block
2nd Degree AV Block Mobitz I (Wenckeback)
2nd Degree AV Block Mobitz II
3rd Degree Block
49 Chapter 5 50
First Degree AV Block - Criteria
Rhythm - regularity between P-P interval
and R-R interval is constant.
Rate - normal, 60 - 100 beats per minute
P wave configuration
„ Same configuration and shape
„ P wave occurs before each QRS complex.
51 Chapter 5 52
1st Degree AV Block – How
Patient Is Affected
Patient can maintain normal cardiac output.
Monitor and report further degeneration and
development of other heart blocks.
53 Chapter 5 54
9
Second Degree AV Block, Second Degree AV Block,
Mobitz I (Wenckeback) Mobitz I (Wenckeback)
Some electrical impulses blocked/non-
conducted from SA node to ventricles at
AV junction region.
AV node conducts electrical impulse to
ventricular conduction pathway until it fails,
then resets in a repetitious pattern.

Chapter 5 55 Chapter 5 56

Second Degree AV Block, Second Degree AV Block,

Mobitz I (Wenckeback) - Criteria
Rhythm
„ P-P interval regular
„ R-R interval irregular due to blocked impulses
Rate
„ Atrial rate within normal limits
„ Ventricular rate slower than atrial rate
Chapter 5
Mobitz I (Wenckeback) - Criteria
P wave configuration
„ Normal sized, upright
„ One P wave for every QRS, with additional P
waves
PR interval - varies, starts short, gets
progressively longer until QRS wave is
dropped, then cycle is restarted
QRS duration - normal .06 - .10 seconds
57 Chapter 5 58

2nd Degree (Wenckeback) – How 2nd Degree (Wenckeback) – How

Patient Is Affected
Patient may not exhibit signs of low cardiac
output until rate decreases to 40 beats per
minute, or lower.
Condition usually results from
inflammation around AV node and is often
temporary.
Patient Is Affected
If patient exhibits signs of low cardiac
output, licensed practitioner should be
notified.
If no low cardiac output signs are exhibited,
monitor patient for progression to third
degree heart block

Chapter 5 59 Chapter 5 60

10
Second Degree AV Block, Second Degree AV Block,
Mobitz II Mobitz II
AKA classical heart block
AV node selects which electrical impulses
to block.
No pattern or reason for dropping QRS
complex exists.
Frequently progresses to third degree AV
block

Chapter 5 61 Chapter 5 62

Second Degree AV Block, Second Degree AV Block,

Mobitz II - Criteria Mobitz II - Criteria
Rhythm P wave configuration
„ P-P interval is regular. „ Normal size
„ R-R interval is irregular.
„ Upright
„ One P wave for every QRS complex, but
Rate additional P waves
„ Atrial rate is within normal limits. PR interval - constant, even after QRS drop
„ Ventricular rate will be slower than atrial rate. occurs
QRS duration - normal, .06 - .10 seconds

Chapter 5 63 Chapter 5 64

2nd Degree Mobitz II – How

Patient Is Affected Third Degree AV Block
Observe patient for signs of low cardiac AKA complete heart block (CHB)
output. All electrical impulses originating above the
Condition can progress within seconds to ventricles are blocked.
third degree AV block or complete heart No correlation exists between atria and ventricle
block. depolarization.

Chapter 5 65 Chapter 5 66

11
Third Degree AV Block - Criteria Third Degree AV Block - Criteria
Rhythm P wave configuration
„ P-P interval is regular. „ Normal size, but may be buried in QRS
„ R-R interval is regular, but different from P-P complex
interval. „ Number of P waves will not correlate to

Rate number of QRS complexes.

„ P waves will outnumber QRS complexes.
„ Atrial rate is 60 - 100 beats per minute.
„ Ventricular is 20 - 40 beats per minute.

Chapter 5 67 Chapter 5 68

3rd Degree AV Block – How the

Third Degree AV Block - Criteria Patient Is Affected
PR interval Patient will show signs of low cardiac
„ Intervals will vary. output and may be unconscious.
„ A long PR interval followed by a short PR Immediate medical intervention may be
interval indicates complete heart block. required.
QRS duration Initiate Code Blue when patient shows first
signs of low cardiac output.
„ Will be constant
„ May be within normal limits, or wider
Rhythm strips should be mounted and
identified in patient’s record.

Chapter 5 69 Chapter 5 70

Branch Bundle Block Branch Bundle Block

Dysrhythmias (BBB)
Occur when one or both ventricular
pathways are damaged
Ventricle(s) with damaged pathway
receive(s) current one cell at a time
Longer contraction time reflected in wider
QRS complex
Dysrhythmias (BBB) - Criteria
Note: leads I, II, and III display similar
characteristics; specific characteristics of
left or right branch identifiable leads V1 -
V6.
Rhythm
„ May be regular or irregular
Rate - atria and ventricles depend on basic
rhythm

Chapter 5 71 Chapter 5 72

12
Branch Bundle Block
Dysrhythmias (BBB) - Criteria
P wave configuration - shape, configuration,
deflection, and coordination with QRS
complex depend on basic rhythm.
PR interval - normal, .12 to .20 seconds
QRS duration - .12 and greater
BBB – How Patient Is Affected
Patient exhibits normal effects of basic
rhythm.
Widening of QRS complex must be
reported to a licensed practitioner
immediately.
Condition may require pacemaker/code
blue.

Chapter 5 73 Chapter 5 74

Rhythms Originating from the Premature Ventricular

Ventricles Contractions (PVC)
Rate of automaticity is 20 - 40 beats per Caused by an ectopic beat that occurs early
minute. in the cycle and originates from the
Current initiated in Purkinje fibers ventricles
Rhythm is longer than normal
depolarization of ventricles.

Chapter 5 75 Chapter 5 76

Premature Ventricular Premature Ventricular

Contraction (PVC) - Criteria Contraction (PVC) - Criteria
Rhythm P wave configurations
„ P-P and R-R intervals are regular with early „ Shape is that of the underlying rhythm.
QRS complexes.
„ P waves not identified on early ventricular
„ Early complex has full compensatory pause.
complex.
Rate
PR interval
„ Atrial and ventricular rates are the same for the
underlying rhythm. „ Follows underlying rhythm
„ Early complexes make ventricular rhythm „ P wave not present in early complex.
faster than normal rhythm.

Chapter 5 77 Chapter 5 78

13
Premature Ventricular
Contraction (PVC) - Criteria
QRS duration
„ Follows underlying rhythm
„ Duration of early complex greater than .12
„ QRS shape is unusual, with T wave in opposite
direction from QRS wave.
Chapter 5
Types of Premature Ventricular
Contractions (PVC)
Bigeminy - every other beat is a PVC.
Trigeminy - every third beat is a PVC.
Quadgeminy -every fourth beat is a PVC.
R on T PVC’s - PVC occurs on the T wave or
the vulnerable period of the ventricle
refractory period.
Coupling - two PVCs occur back to back.
Chapter 5
PVC – How Patient Is Affected
Watch for symptoms of low cardiac output.
Notify licensed practitioner if they occur.
Treatment includes oxygen.
Chapter 5
Types of Premature Ventricular
Contractions (PVC)
Unifocal - early beat (has similar shape and size
suggesting only one irritable focus present)
Multifocal - varied shapes and forms of the PVCs
Interpolated - PVC occurs during the normal R-R
interval without interrupting the normal cycle.
Occasional - more than one to four PVCs per minute
Frequent - more than five to seven PVCs per minute
79 Chapter 5 80
PVC – How Patient Is Affected
Frequency of PVCs determines their
significance.
More complex PVCs indicate increased risk
of developing more serious ventricular
dysrhythmias.
81 Chapter 5 82
Ventricular Tachycardia (Vtach)
Three or more PVCs occur in a row.
Ventricles are in continuous state of
contraction-relaxation.
83 Chapter 5 84
14
Ventricular Tachycardia (Vtach)
- Criteria
Rhythm
„ P-P interval usually not identifiable.
„ R-R interval usually regular, can be slightly
irregular, at times.
Rate
„ Atrial rate cannot be determined.
„ Ventricular rate - 100 - 200 beats per minute.
Ventricular Tachycardia (Vtach)
- Criteria
P wave configurations - P wave usually
absent
PR interval cannot be determined
QRS duration
„ Greater than .12 seconds
„ T wave in opposite direction (usually down)
from QRS complex

Chapter 5 85 Chapter 5 86

Vtach – How Patient Is Affected Vtach – How Patient Is Affected

Lost atrial kick and decreased ventricular
filling time result in decreased cardiac
output.
Approx. 50% of patients become
unconscious immediately.
Notify licensed practitioner.
If patient is unresponsive, issue code blue,
begin CPR, use emergency equipment.
Mount rhythm strips in patient’s medical
record.
If patient is responsive, licensed practitioner
may initiate treatment plan.

Chapter 5 87 Chapter 5 88

Ventricular Fibrillation (Vfib) -

Ventricular Fibrillation (Vfib) Criteria
Chaotic asynchronous electrical activity Rhythm
within ventricular tissue results in no „ P-P interval cannot be determined.
cardiac output. „ R-R interval, if able to determine, will be
irregular.
Rate
„ Atrial rate cannot be determined.
„ Ventricular rate, if identifiable, will be greater
than 300 beats per minute.

Chapter 5 89 Chapter 5 90

15
Ventricular Fibrillation (Vfib) -
Criteria
P wave configurations - not identifiable
PR interval - cannot be identified
QRS duration - cannot be determined
Chapter 5
Asystole
AKA straight line or flat line
No electrical activity is present in the
myocardium.
Chapter 5
Asystole – How Patient Is
Affected
Situation is life-threatening.
Patient is in cardiac arrest; initiate
emergency procedures.
Chapter 5
Vfib – How Patient Is Affected
Patient will be unresponsive.
Code blue situation is present.
Begin CPR and emergency measures
immediately.
Advanced cardiac life support (ACLS)
should begin immediately.
If patient is conscious and talking, leads are
loose or detached.
91 Chapter 5 92
Asystole -Criteria
Rhythm - no P-P or R-R intervals are present.
Rate - no atrial or ventricular rates are present.
P wave configurations - no P waves are present.
PR interval - none, since no waveforms are
present.
QRS duration - not measurable, no waveforms are
present.
93 Chapter 5 94
Electronic Pacemaker Rhythms –
Background Information
AKA artificial pacemakers
Deliver electrical impulse to myocardium,
causing cells to depolarize
Can pace the atria, ventricles, or both
Approximately 115,000 permanent
pacemakers implanted each year
95 Chapter 5 96
16
Electronic Pacemaker Rhythm Evaluating Pacemaker Function
Pacing spike
„ Thin spike on ECG tracing indicating electrical
current from pacemaker
„ After spike, either a P wave or QRS complex
will appear.

Chapter 5 97 Chapter 5 98

Seven Steps To Evaluating

Evaluating Pacemaker Function Pacemaker ECG Tracing
AV delay Step 1 - What are the rate and regularity of
„ Similar to PR interval on normal rhythm tracing the paced rhythm?
„ Measured from atrial spike to ventricle spike Step 2 - What is the rate and regularity of
„ Normally .12 - .20 seconds the intrinsic rhythm?
„ If patient has normal P wave and pacer induced Step 3 - Is the atrial lead sensing
ventricular complex, measure from beginning appropriate?
of P wave to ventricular spike.
Step 4 - Is atrial capture present?

Chapter 5 99 Chapter 5 100

Seven Steps To Evaluating

Pacemaker ECG Tracing What Questions Do You Have?
Step 5 - Is AV delay appropriate?
Step 6 - Is ventricular sensing appropriate?
Step 7 - Is ventricular capture present?
Note - If patient does not have an AV
sequential pacemaker, steps 3 through 5 can
be eliminated.

Chapter 5 101 Chapter 5 102

17