Arrhythmia Reference Guide

Arrhythmia Reference Guide
Quick access library for arrhythmias
Rhythm Category
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Sinus
Atrial
Junctional
Ventricular
Atrioventricular
Pacemaker
All
Recommended EKG Training

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Cardiac Rhythm Analysis

Sinus Rhythms
Atrial Rhythms
Junctional Rhythms
Ventricular Rhythms
Atrioventricular Rhythms
Pacemake Rhythmsr
Welcome to our EKG arrhythmia reference guide. Select one of the titles below to view an EKG strip along with our guide to reading that
EKG. To narrow your focus to a specific category, use the buttons in the right margin.
Accelerated Idioventricular Rhythm

Rhythm
Regular
Rate
50-120 bpm
P Wave
Absent
PR Interval
Not measurable
QRS
Wide (>0.10 sec), bizarre looking
Notes
Caliper Time Interval: ___ seconds
Accelerated Junctional Rhythm

Rhythm
Regular
Rate
Normal (60-100 bpm)
P Wave
Present before, during (hidden) or after QRS, if visible it is inverted
PR Interval
Not measurable
QRS
Normal (0.06-0.10 sec)
Notes
Asystole
Rhythm
Not present
Rate
Absent
P Wave
Absent
PR Interval
Absent
QRS
Absent
Notes
Confirm with multiple leads
Atrial Fibrillation
Rhythm
Irregular
Rate
Very fast (> 350 bpm) for Atrial, but ventricular rate may be slow, normal or fast
P Wave
Absent - erratic waves are present
PR Interval
Absent
QRS
Normal but may be widened if there are conduction delays
Notes
Atrial Flutter
Rhythm
Regular or irregular
Rate
Fast (250-350 bpm) for Atrial, but ventricular rate is often slower
P Wave
Not observable, but saw-toothed flutter waves are present
PR Interval
Not measureable
QRS
Notes
Bundle Branch Block

Rhythm
Regular
Rate
The underlying rate
P Wave
Normal
PR Interval
QRS
Wide (>0.12 sec)
Notes
First Degree Heart Block

Rhythm
Regular
Rate
The underlying rate
P Wave
Normal
PR Interval
Prolonged (>0.20 sec)
QRS
Notes
A first degree AV block occurs when electrical impulses moving through the Atrioventricular (AV) node are
delayed (but not blocked). First degree indicates slowed conduction without missed beats.
Idioventricular Rhythm
Rhythm
Regular
Rate
Slow (20-40 bpm)
P Wave
Absent
PR Interval
Not measurable
QRS
Wide (>0.10 sec), bizarre appearance
Notes
Junctional Escape Rhythm

Rhythm
Regular
Rate
Slow (40-60 bpm)
P Wave
PR Interval
Not measurable
QRS
Notes
Junctional Tachycardia
Rhythm
Regular
Rate
Fast (100-180 bpm)
P Wave
PR Interval
Absent or short
QRS
Notes
Multifocal Atrial Tachycardia

Rhythm
Irregular
Rate
Fast (> 100 bpm)
P Wave
Often changing shape and size from beat to beat (at least three differing forms)
PR Interval
Variable
QRS
Notes
T wave is often distorted Also review wandering atrial pacemaker lesson
Normal Sinus Rhythm

Rhythm
Regular
Rate
Normal (60-100 bpm)
P Wave
Normal (positive & precedes each QRS)
PR Interval
QRS
Notes
Pacemaker Failure to Capture

Rhythm
Irregular
Rate
Slow or normal
P Wave
PR Interval
QRS
Notes
Pacemaker spikes are not followed by P waves or QRS complexes
Pacemaker Failure to Pace

Rhythm
Irregular
Rate
P Wave
PR Interval
QRS
Notes
Pacemaker spikes do not appear
Pacemaker Single Chamber Atrial

Rhythm
Regular
Rate
60 bpm
P Wave
Normal
PR Interval
Normal
QRS
Normal
Notes
Premature Atrial Complex

Rhythm
Irregular
Rate
Usually normal but depends on underlying rhythm
P Wave
Premature, positive and shape is abnormal
PR Interval
Normal or longer
QRS
0.10 sec or less
Notes
Premature Junctional Complex

Rhythm
Regular with premature beats
Rate
The underlying rate
P Wave
PR Interval
Absent or short
QRS
Notes
Premature Ventricular Complex

Rhythm
Irregular
Rate
The underlying rate
P Wave
Absent
PR Interval
Not measurable
QRS
Wide (> 0.10 sec), bizarre appearance
Notes
Two PVCs together are termed a couplet while three PVCs in a row with a fast rhythm is ventricular
tachycardia
Premature Ventricular Complex Bigeminy

Rhythm
Irregular
Rate
The underlying rate
P Wave
Absent
PR Interval
Not measurable
QRS
Notes
PVC appears every second beat
Premature Ventricular Complex Quadrigeminy

Rhythm
Irregular
Rate
The underlying rate
P Wave
Absent
PR Interval
Not measurable
QRS
Notes
PVC appears every fourth beat
Premature Ventricular Complex Trigeminy

Rhythm
Irregular
Rate
The underlying rate
P Wave
Absent
PR Interval
Not measurable
QRS
Notes
PVC appears every third beat
Second Degree Heart Block Type I

Rhythm
Irregular but with progressively longer PR interval lengthening
Rate
The underlying rate
P Wave
Normal
PR Interval
Progressively longer until a QRS complex is missed, then cycle repeats
QRS
Notes
Second Degree Heart Block Type II

Rhythm
Regular (atrial) and irregular (ventricular)
Rate
Characterized by Atrial rate usually faster than ventricular rate (usually slow)
P Wave
Normal form, but more P waves than QRS complexes
PR Interval
Normal or prolonged
QRS
Normal or wide
Notes
Sinoatrial Block
Rhythm
Irregular when SA block occurs
Rate
Normal or slow
P Wave
Normal
PR Interval
QRS
Notes
Pause time is an integer multiple of the P-P interval Try to identify specific type of atrial tachycardia - see
other pages
Sinus Arrest
Rhythm
Irregular due to pause
Rate
Normal to slow
P Wave
Normal
PR Interval
QRS
Notes
Pause time is not an integer multiple of the P-P interval
Sinus Arrhythmia
Rhythm
Irregular, varying with respiration
Rate
Normal (60-100 bpm) and rate may increase during inspiration
P Wave
Normal
PR Interval
QRS
Notes
Heart rate frequently increases with inspiration, decreasing with expiration
Sinus Bradycardia
Rhythm
Regular
Rate
Slow (< 60 bpm)
P Wave
Normal
PR Interval
QRS
Notes
Sinus Tachycardia
Rhythm
Regular
Rate
Fast (> 100 bpm)
P Wave
Normal, may merge with T wave at very fast rates
PR Interval
QRS
Notes
QT interval shortens with increasing heart rate
Supraventricular Tachycardia
Rhythm
Regular
Rate
Fast (150-250 bpm)
P Wave
Merged with T wave
PR Interval
Normal (0.12 sec)
QRS
Normal (.10 sec)
Notes
PR interval can be difficult to measure
Third Degree Heart Block

Rhythm
Regular, but atrial and ventricular rhythms are independent
Rate
Characterized by Atrial rate usually normal and faster than ventricular rate
P Wave
Normal shape and size, may appear within QRS complexes
PR Interval
Absent: the atria and ventricles beat independently.
QRS
Normal, but wide if junctional escape focus
Notes
Ventricular Fibrillation
Rhythm
Highly irregular
Rate
Unmeasurable
P Wave
Absent
PR Interval
Not measurable
QRS
None
Notes
EKG tracings is a wavy line
Ventricular Tachycardia
Rhythm
Regular
Rate
Fast (100-250 bpm)
P Wave
Absent
PR Interval
Not measurable
QRS
Wide (>0.10 sec), bizarre appearance
Notes
Ventricular Tachycardia Monomorphic

Rhythm
Regular
Rate
Fast (100-250 bpm)
P Wave
Absent
PR Interval
Not measurable
QRS
Notes
Ventricular Tachycardia Polymorphic

Rhythm
Regular or irregular
Rate
Fast (100-300 bpm)
P Wave
Absent
PR Interval
Not measurable
QRS
Normal or wide (>0.10 sec), bizarre looking
Notes
Ventricular Tachycardia Torsade de Pointes

Rhythm
Irregular
Rate
Fast (200-250 bpm)
P Wave
Absent
PR Interval
Not measurable
QRS
Notes
Wandering Atrial Pacemaker

Rhythm
May be irregular
Rate
Normal (60-100 bpm)
P Wave
Changing shape and size from beat to beat (at least three diffferent forms)
PR Interval
Variable
QRS
Notes
T wave normal. If heart rate exceeds 100 bpm, then rhythm may be multifocal atrial tachycardia (MAP)
Wolff-Parkinson-White Syndrome
Rhythm
Regular unless atrial fibrillation present
Rate
Normal (60-100 bpm)
P Wave
Normal
PR Interval
Can be short (<0.12 sec)
QRS
Usually wide (> 0.12 sec)
Notes
Look for short PR interval and/or delta wave A delta wave (positive or negative) distorts the early part of the
QRS complex
http://www.practicalclinicalskills.com/ekg-reference-guide.aspx
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http://www.practicalclinicalskills.com/abnormal-ekg.aspx
http://www.rn.org/courses/coursematerial-187.pdf
Heart Sounds, Lung Sounds Reference

Guide
Quick access library featuring full and half speed playback, phonocardiograms
and listening tips.
This reference guide is organized by auscultatory location. This comprehensive online library of heart and lung sounds offers playback at
both normal and half speeds. Listening tips are available along with a phonocardiogram (or waveform for lung sounds).
Aortic Sclerosis (Musical Murmur)
Acute Pericarditis
Aortic Regurgitation (Decrescendo Diastolic Murmur)
Aortic Regurgitation - Mild
Aortic Regurgitation - Moderate
Aortic Regurgitation - Severe
Aortic Stenosis (Diamond Shaped Systolic Murmur)
Aortic Stenosis - Mild
Aortic Stenosis - Mod Regur. Mild
Aortic Stenosis - Severe
Aortic Stenosis Moderate and Regurgitation Mild - Rheumatic Origin
Arrhythmogenic RV Dysplasia
Atrial Septal Defect
Bronchial
Bronchophony - Abnormal
Bronchophony - Healthy
Bronchovesicular
Cardiomyopathy - Congestive Moderate
Coarctation of the Aorta
Commotio Cordis
Crackles - Coarse (Rales)
Crackles - Early Inspiratory (Rales)
Crackles - Fine (Rales)
Crackles - High Pitched (Rales)
Crackles - Late Inspiratory (Rales)
Crackles - Low Pitched (Rales)
Ebstein's Anomaly
Egophony - a
Egophony - e
Exercise - Heart Rate 120
First and Second Heart Sounds - Normal and Unsplit
First and Second Heart Sounds - Reduced Intensity
First Heart Sound (Markedly Split)
First Heart Sound (Minimally Split)
First Heart Sound - Decreased Intensity
First Heart Sound - Loud
First Heart Sound plus Aortic Ejection Click
Fourth Heart Sound
Fourth Heart Sound Gallop
Hypertrophic Cardiomyopathy
Innocent Murmur
Innocent Systolic Ejection Murmur - Standing
Innocent Systolic Ejection Murmur - Supine
Mediastinal Crunch
Mid-Systolic Click
Mitral Regurgitation
Mitral Regurgitation (Pan-systolic Murmur)
Mitral Regurgitation - Severe
Mitral Regurgitation and Aortic Regurgitation
Mitral Stenosis (Diastolic Murmur)
Mitral Stenosis - Mild
Mitral Stenosis - Moderate
Mitral Stenosis - Severe
Mitral Stenosis Severe and Regurgitation Mild - Rheumatic Origin
Mitral Valve Leaflet Prolapse
Mitral Valve Prolapse (Click with late systolic murmur)
Mitral Valve Prolapse with Mid Systolic Click - Standing
Myocarditis
Opening Snap and Second Heart Sound
Patent Ductus Arteriosus
Pleural Rubs
Prosthetic Heart Sound - Aortic
Prosthetic Heart Sound - Mitral
Pulmonary Stenosis
Pulmonic Regurgitation - Mild
Rhonchi - Low Pitched Wheezes
Second Heart Sound - Physiologically Split
Second Heart Sound - Fixed Splitting
Second Heart Sound - Physiologic Split
Second Heart Sound - Splitting
Second Heart Sound and a Tumor Plop
Second Heart Sound and Late Systolic Click
Second Heart Sound with Fixed Splitting
Second Heart Sound with Persistent Splitting
Second Heart Sound: Fixed Splitting, Decreased Aortic Intensity
Second Heart Sound: Fixed Splitting, Increased Aortic Intensity
Stridor
Summation Gallop at 120 beats per minute
Tetralogy of Fallot
Third and Fourth Heart Sound Gallop
Third Heart Sound - Physiologic
Third Heart Sound Gallop - Abnormal
Tricuspid Regurgitation - Severe
Tricuspid Stenosis - Moderate
Ventricular Septal Defect
Vesicular - Diminished
Vesicular - Normal
Wheeze
Wheezes - Expiratory
Wheezes - High Pitched
Wheezes - Low Pitched
Wheezes - Monophonic
Wheezes - Polyphonic
Whispered Pectoriloquy - Abnormal
Whispered Pectoriloquy - Healthy
http://www.practicalclinicalskills.com/heart-lung-sounds-reference-guide.aspx
Basics of Lung Sounds

Course Overview and Lesson Access
Table of Contents
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Vesicular - Normal
Crackles - Fine (Rales)
Crackles - Coarse (Rales)
Wheeze
Rhonchi - Low Pitched Wheezes
Bronchial
Pleural Rubs
Bronchovesicular
Advertisement
Auscultation Course Overview

The goal of this basic course in lung sounds is to improve auscultation observational skills. We focus on describing important breath
sounds and in providing recordings of each. Many students find that waveform tracings aid in learning lung sounds; we have included
dynamic (moving cursor) waveforms with each lesson. The anatomy pages use illustrations to reveal an example of each lung sound
(anatomy not yet available on smartphones).
About the author:

Diane Wrigley , Physician Assistant and national educator for continuing education.
How To Use Course Lessons

Please use good quality headphones or earphones.
Each lesson consists of multiple pages: text description with audio recording and dynamic waveform pages. Most lessons include a cardiac
or lung animation as well. To navigate pages within a lesson, use the navigation bar which will appear on each lesson page.
After completing a lesson, use the blue arrows to view the next lesson. Lessons can also be accessed by using the Table of Contents found
in the left margin.
Quick Quiz
Test your knowledge! Try our Quick Quiz.
http://www.practicalclinicalskills.com/auscultation-course-contents.aspx?courseid=201
Intermediate Lung Sounds

Course Overview and Lesson Access
Table of Contents
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Vesicular - Diminished
Bronchophony - Healthy
Bronchophony - Abnormal
Egophony - e
Egophony - a
Whispered Pectoriloquy - Healthy
Whispered Pectoriloquy - Abnormal
Wheeze - Expiratory
Wheeze - Monophonic
10
Wheeze - Polyphonic
11
Crackles - Early Inspiratory (Rales)
12
Crackles - Late Inspiratory (Rales)
13
Stridor
Auscultation Course Overview

The goal of this intermediate course is to expand your observational skills when auscultating breath sounds. The course lessons include
voiced sounds: bronchophony, egophony and whispered pectoriloquy. We also provide auscultation lessons on several types of wheezes,
crackles and stridor. Each of these lung sound lessons includes audio, text and dynamic waveform. The anatomy pages use illustrations to
reveal an example of each lung sound (anatomy not yet available on smartphones).
About the author:

Diane Wrigley , Physician Assistant and national educator for continuing education.
How To Use Course Lessons

Please use good quality headphones or earphones.
Each lesson consists of multiple pages: text description with audio recording and dynamic waveform pages. Most lessons include a cardiac
or lung animation as well. To navigate pages within a lesson, use the navigation bar which will appear on each lesson page.
After completing a lesson, use the blue arrows to view the next lesson. Lessons can also be accessed by using the Table of Contents found
in the left margin.
Quick Quiz
Test your knowledge! Try our Quick Quiz.
Auscultation Areas
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Aortic
Pulmonic
Erb's Point
Tricuspid
Mitral
Breath Sounds
All Sounds
Course(s) covering this sound:

Systolic Murmurs
Erbs-Point Auscultation Reference Guide

and listening tips.
Auscultation Location
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Aortic Area
Pulmonic Area
Erb's Point
Tricuspid Area
Mitral Area
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Breath Sounds
All Sounds
Advertisement
Acute Pericarditis
Aortic Regurgitation (Decrescendo Diastolic Murmur)
Aortic Regurgitation - Mild
Aortic Regurgitation - Moderate
Aortic Regurgitation - Severe
Mediastinal Crunch
http://www.practicalclinicalskills.com/heart-lung-sounds-reference-guide-area.aspx?Position=Erbs-Point
Pulmonic Auscultation Reference Guide

and listening tips.
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Aortic Area
Pulmonic Area
Erb's Point
Tricuspid Area
Mitral Area
Breath Sounds
All Sounds
Advertisement
Atrial Septal Defect
Innocent Murmur
Patent Ductus Arteriosus
Pulmonary Stenosis
Pulmonic Regurgitation - Mild
Second Heart Sound - Physiologically Split
Second Heart Sound - Fixed Splitting
Second Heart Sound - Physiologic Split
Second Heart Sound - Splitting
Second Heart Sound with Fixed Splitting
Second Heart Sound with Persistent Splitting
Second Heart Sound: Fixed Splitting, Decreased Aortic Intensity
http://www.practicalclinicalskills.com/heart-lung-sounds-reference-guide-area.aspx?Position=Pulmonic
Aortic Auscultation Reference Guide

and listening tips.
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Aortic Area
Pulmonic Area
Erb's Point
Tricuspid Area
Mitral Area
Breath Sounds
All Sounds
Aortic Stenosis (Diamond Shaped Systolic Murmur)
Aortic Stenosis - Mild
Aortic Stenosis - Mod Regur. Mild
Aortic Stenosis Moderate and Regurgitation Mild - Rheumatic Origin
Coarctation of the Aorta
First Heart Sound plus Aortic Ejection Click
Prosthetic Heart Sound - Aortic
Second Heart Sound: Fixed Splitting, Increased Aortic Intensity
http://www.practicalclinicalskills.com/heart-lung-sounds-reference-guide-area.aspx?Position=Aortic
Tricuspid Auscultation Reference Guide

and listening tips.
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Aortic Area
Pulmonic Area
Erb's Point
Tricuspid Area
Mitral Area
Breath Sounds
All Sounds
Arrhythmogenic RV Dysplasia
Ebstein's Anomaly
First Heart Sound (Markedly Split)
First Heart Sound (Minimally Split)
Innocent Systolic Ejection Murmur - Standing
Innocent Systolic Ejection Murmur - Supine
Tetralogy of Fallot
Tricuspid Regurgitation - Severe
Tricuspid Stenosis - Moderate
Ventricular Septal Defect
http://www.practicalclinicalskills.com/heart-lung-sounds-reference-guide-area.aspx?Position=Tricuspid
Mitral Auscultation Reference Guide

and listening tips.
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Aortic Area
Pulmonic Area
Erb's Point
Tricuspid Area
Mitral Area
Breath Sounds
All Sounds
Advertisement
Cardiomyopathy - Congestive Moderate
Commotio Cordis
Exercise - Heart Rate 120
First and Second Heart Sounds - Normal and Unsplit
First and Second Heart Sounds - Reduced Intensity
First Heart Sound - Decreased Intensity
First Heart Sound - Loud
Fourth Heart Sound
Fourth Heart Sound Gallop
Hypertrophic Cardiomyopathy
Mid-Systolic Click
Mitral Regurgitation
Mitral Regurgitation (Pan-systolic Murmur)
Mitral Regurgitation - Severe
Mitral Regurgitation and Aortic Regurgitation
Mitral Stenosis (Diastolic Murmur)
Mitral Stenosis - Mild
Mitral Stenosis - Moderate
Mitral Stenosis - Severe
Mitral Stenosis Severe and Regurgitation Mild - Rheumatic Origin
Mitral Valve Leaflet Prolapse
Mitral Valve Prolapse (Click with late systolic murmur)
Mitral Valve Prolapse with Mid Systolic Click - Standing
Myocarditis
Opening Snap and Second Heart Sound
Prosthetic Heart Sound - Mitral
Second Heart Sound and a Tumor Plop
Second Heart Sound and Late Systolic Click
Summation Gallop at 120 beats per minute
Third and Fourth Heart Sound Gallop
Third Heart Sound - Physiologic
Third Heart Sound Gallop - Abnormal
http://www.practicalclinicalskills.com/heart-lung-sounds-reference-guide-area.aspx?Position=Mitral
http://www.practicalclinicalskills.com/breath-sounds-reference-guide.aspx

Arrhythmia Reference Guide

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Arrhythmia Reference Guide

Quick access library for arrhythmias

Recommended EKG Training

Cardiac Rhythm Analysis

Accelerated Idioventricular Rhythm

Wide (>0.10 sec), bizarre looking

Caliper Time Interval: ___ seconds

Accelerated Junctional Rhythm

Normal (60-100 bpm)

Present before, during (hidden) or after QRS, if visible it is inverted

Normal (0.06-0.10 sec)

Confirm with multiple leads

Caliper Time Interval: ___ seconds

Absent - erratic waves are present

Normal but may be widened if there are conduction delays

Not observable, but saw-toothed flutter waves are present

Normal (0.06-0.10 sec)

Bundle Branch Block

The underlying rate

Normal (0.12-0.20 sec)

Wide (>0.12 sec)

First Degree Heart Block

The underlying rate

Prolonged (>0.20 sec)

Normal (0.06-0.10 sec)

Caliper Time Interval: ___ seconds

Slow (20-40 bpm)

Wide (>0.10 sec), bizarre appearance

Junctional Escape Rhythm

Slow (40-60 bpm)

Present before, during (hidden) or after QRS, if visible it is inverted

Normal (0.06-0.10 sec)

Fast (100-180 bpm)

Present before, during (hidden) or after QRS, if visible it is inverted

Normal (0.06-0.10 sec)

Multifocal Atrial Tachycardia

Fast (> 100 bpm)

Normal (0.06-0.10 sec)

T wave is often distorted Also review wandering atrial pacemaker lesson

Normal Sinus Rhythm

Normal (60-100 bpm)

Normal (positive & precedes each QRS)

Normal (0.12-0.20 sec)

Normal (0.06-0.10 sec)

Pacemaker Failure to Capture

Pacemaker spikes are not followed by P waves or QRS complexes

Pacemaker Failure to Pace

Pacemaker spikes do not appear

Pacemaker Single Chamber Atrial

Premature Atrial Complex

Usually normal but depends on underlying rhythm

Premature, positive and shape is abnormal

0.10 sec or less

Premature Junctional Complex

Regular with premature beats

The underlying rate

Present before, during (hidden) or after QRS, if visible it is inverted

Normal (0.06-0.10 sec)

Premature Ventricular Complex

The underlying rate

Wide (> 0.10 sec), bizarre appearance

Premature Ventricular Complex Bigeminy

The underlying rate

Wide (> 0.10 sec), bizarre appearance