ARRHYTHMIA

RECOGNITION

T
Q

T
Q

T
Q

T
Q

Sinus Rhythm

Sinus Rhythm

Sinus Rhythm

Normal Sinus Rhythm

Look at the p waves:
rate is 60-100/min
cycle length do not vary by 10%
PR interval is 0.12 sec. or more
Lead II

Normal Sinus Rhythm

Look at the p waves:
same contour in same lead?
Upright in I, II, aVF & left precordial
leads
followed by QRST?
Lead II

Sinus
Sinus Bradycardia
Bradycardia
Regularly occurring PQRST
Rate < 60 / min

Rate = 48/min

Rate = 48/min

56/min

Sinus
Sinus Bradycardia
Bradycardia

Sinus
Sinus Tachycardia
Tachycardia
Regularly occurring PQRST
Rate > 100 / min
Rate = 111/min

Rate = 111/min

Rate = 111/min

105/min

Sinus
Sinus Tachycardia
Tachycardia

Sinus
Sinus Arrhythmia
Arrhythmia
Identical but irregularly
occurring PQRST
longest PP or RR > the
shortest by 0.16 sec or more
Rate = 71/min
Rate = 94/min

Rate = 79/min

Rate = 94/min

Sinus
Sinus Arrhythmia
Arrhythmia

Coronary
Coronary Sinus
Sinus Rhythm
Rhythm
Regularly occurring PQRST
Inverted P waves at II, III, AVF

Coronary
Coronary Sinus
Sinus Rhythm
Rhythm

Sinus Rhythm

Premature
Premature Atrial
Atrial Contraction
Contraction
Prematurely occurring PQRTS complex
P wave different in configuration
from the sinus beat.
PR interval often long.
QRS narrow.

Wandering
Wandering Atrial
Atrial
Pacemaker
Pacemaker
Variable P wave morphology
Impulses originate from varying
points in the atrium

Wandering
Wandering Atrial
Atrial Pacemaker
Pacemaker

Multifocal
Multifocal Atrial
Atrial
Tachycardia
Tachycardia
Impulses originate irregularly
and rapidly at different points
in the atrium
Varying P wave, PR, PP and RR intervals
Ventricular rate > 100/min

Multifocal
Multifocal Atrial
Atrial Tachycardia
Tachycardia

Paroxysmal
Paroxysmal Supraventricular
Supraventricular Tachycardia
Tachycardia

AVN Conduction
with unilateral block

(N) AVN Conduction

pathway
pathway

pathway
pathway

AV
AVNODE
NODE

Atrial
Atrial Flutter
Flutter
Atrial rate = 220-300/min
( P as flutter waves )
Variable degree of AV block
( irregular RR interval )

Atrial
Atrial Flutter
Flutter

Atrial
Atrial Fibrillation
Fibrillation
No discernible P waves
Irregular RR interval

Atrial
Atrial Fibrillation
Fibrillation

Junctional
Junctional Rhythm
Rhythm
Impulses from the AV node
P wave inverted or buried w/in
QRS or follows the QRS
Rate slow
QRS narrow

Junctional
Junctional Rhythm
Rhythm

Junctional
Junctional Premature
Premature
Contraction
Contraction
Prematurely occurring PQRST.
Inverted P wave that may precede,
be incorporated within, or may follow
the QRS complex.
QRS narrow.

Normal Cardiac Depolarization

Atrioventricular Blocks

R
T

P
Q
S

First Degree
Atrioventricular Blocks

R
T

P
Q
Do you have a normal P wave?
Do you have a normal PR segment?
Do you have a normal PR interval?
Do you have a normal QRS-T?

Yes
No
Prolonged (> 0.20 sec)
Yes

Criteria for First Degree Heart

P waves present
Block

QRS complexes present

P waves morphology and axis usual for the
subject
QRS complexes morphology and axis usual for
the subject
One P wave to each QRS complex
P-R interval constant

P-R interval must be prolonged

( i.e. > 0.21 sec )

FIRST
FIRST DEGREE
DEGREE
AV
AV BLOCK
BLOCK
PR interval > 0.20 sec

0.28
0.28sec
sec

0.28
0.28sec
sec

0.28
0.28sec
sec

FIRST
FIRST DEGREE
DEGREE AV
AV BLOCK
BLOCK

Second Degree
Atrioventricular Blocks
Do you have a normal P wave?
Yes
Do you have a normal PR segment?
No
Do you have a normal PR interval?
No
Will there be intermittent P waves not
followed by QRS complex? Yes (dropped beats)

Second Degree
Atrioventricular Block

Type I - Mobitz type I or

Wenchebach

Type II - Mobitz type II

Criteria for Type I Second

Degree
P waves present
Atrio-Ventricular
Block
QRS complexes present
(Wenckebach)

P wave morphology and axis usual for the subject

QRS complexes morphology and axis usual for the
subject
Progressive prolongation of the P-R interval with
each succeeding beat until one P wave occurs
without a QRS (i.e. dropped beat)

Criteria for Type I Second

Degree
Longest P-R interval is the one immediately before the
Atrio-Ventricular Block
dropped beat.
(Wenckebach)
Shortest P-R interval is the one associated with the

first conducted beat after the dropped beat.

P-R interval before the blocked beat increase and do
so by progressively decreasing amounts so that the
consecutive R-R intervals before the blocked beat
actually progressively shorten.

SECOND
SECOND DEGREE
DEGREE AV
AV BLOCK
BLOCK
MOBITZ
MOBITZ II
Progressive lengthening
of PR interval w/ intermittent
drop beats .

0.20
0.20sec
sec

0.28
0.28sec
sec

0.20
0.20sec
sec

Criteria for Type II Second

Degree Atrio-Ventricular Block
(Mobitz
II)
P waves present

QRS complexes present

P waves morphology and axis usual for the
subject
QRS morphology and axis usual for the subject
P-R interval of conducted beats normal or
prolonged

Criteria for Type II Second

Degree Atrio-Ventricular Block
(Mobitz
II) of observation, one P wave is not
Within period

followed by a QRS complex.

No change in P-R interval before the transient
failure of atrio-ventricular conduction.
n P waves to (n-1) QRS complexes for each
example of transient type II block. (n will be 3 or
more*)

Criteria for Type II Second

Degree Atrio-Ventricular Block
(Mobitz
Failure of II)
AV conduction may occur more than
once within the period, but it is not seen in
relation to two or more consecutive P waves.

P-R interval constant for all conducted beats

QRS complexes after the block have the same

morphology as those preceding it

SECOND
SECOND DEGREE
DEGREE
AV
AV BLOCK
BLOCK
MOBITZ
MOBITZ IIII
Fixed PR interval
w/ intermittent
drop beats .

0.18
0.18sec
sec

0.18
0.18sec
sec

BLOCK AT THE
Bundle of His
Bilateral bundle
branches

Trifascicle

0.18
0.18sec
sec

SECOND
SECOND DEGREE
DEGREE AV
AV BLOCK
BLOCK
MOBITZ
MOBITZ IIII

22 :: 11 AV
AV BLOCK
BLOCK

Criteria for High-Grade

Atrio-Ventricular Block

P waves present
QRS complexes present
P wave morphology and axis usual for the
subject
QRS morphology and axis usual for the subject
and the lead

Criteria for High-Grade

Atrio-Ventricular Block

Some P waves followed by QRS complexes and

some are not
Atrio-ventricular conduction ratio is
3:1 or higher
P-R interval following a QRS is constant but may
be normal or prolonged

HIGH
HIGH GRADE
GRADE AV
AV BLOCK
BLOCK

Criteria for Third Degree

(Complete) Atrio-Ventricular
No recognizable consistent or meaningful
Block
relationship between atrial and ventricular activity

QRS complexes often abnormal in shape,

duration and axis (occasionally normal)
QRS morphology constant
QRS rate constant ( 15-60 beats/min )
Any form of atrial activity seen (most commonly
sinus initiated)

THIRD
THIRD DEGREE
DEGREE
AV
AV BLOCK
BLOCK

Complete atrioventricular block

Impulses originate at both SA node and at
the subsidiary pacemaker below the block
Do you have regularly occurring P waves and QRS complexes? Yes
Are the P waves related to the QRST complexes? No
Is the atrial rate < = > ventricular rate? greater
Ventricular rate = 83 BPM

Atrial
Atrialrate
rate==100
100BPM
BPM

Ventricular rate = 83 BPM

Atrial
Atrialrate
rate==100
100BPM
BPM

Atrial
Atrialrate
rate==100
100BPM
BPM

THIRD
THIRD DEGREE
DEGREE AV
AV BLOCK
BLOCK
WITH
WITH SUPRAVENTRICULAR
SUPRAVENTRICULAR ESCAPE
ESCAPE RHYTHM
RHYTHM

THIRD
THIRD DEGREE
DEGREE AV
AV BLOCK
BLOCK
WITH
WITH VENTRICULAR
VENTRICULAR ESCAPE
ESCAPE RHYTHM
RHYTHM

oo
AV
Dissociation
w/o
3
AV Dissociation w/o 3 AV
AV Block
Block

Impulses originate at both SA node and

at a subsidiary pacemaker below that is
firing at the same rate (acchrocage) or
even faster than that of the SA node
Do you have regularly occurring P waves and QRS complexes?
Are the P waves related to the QRST complexes?

Yes

Most of the time, NO

Sometimes yes
Is the atrial rate < = > ventricular rate?
Less than or equal

Normal Cardiac Depolarization

Premature Ventricular Contraction

Prematurely occurring complex.
Wide, bizarre looking QRS complex.
Usually no preceding P wave.
T wave opposite in deflection to the QRS
complex.
Complete compensatory pause following
every premature beat.

Premature Ventricular Contraction

in Couplets
Two Premature ventricular
contractions occurring consecutively

Premature Ventricular Contraction

in Bigeminy
Alternating normal sinus beat and
a PVC

Premature Ventricular Contraction

in Trigeminy
PVCs regularly occurring every
third beat

Premature Ventricular Contraction

in Quadrigeminy
PVCs regularly occurring every
fourth beat

Multifocal Premature Ventricular

Contraction
PVCs coming from different foci in
the ventricle
PVCs assuming different polarities
in a single lead
PVCs of different morphology and
coupling interval

Premature Ventricular Contraction

R on T Phenomenon
R or Q of the PVC occurring at the
T wave of the preceding sinus beat
Most dangerous PVC

Ventricular Tachycardia
At least 3 consecutive PVCs
Rapid, bizarre, wide QRS complexes
(> 0.10 sec)
No P wave (ventricular impulse
origin)
Rate > 140 / min

Ventricular Tachycardia

Ventricular Tachycardia

Ventricular Fibrillation

Ventricular Fibrillation

Idioventricular Rhythm
Impulse ventricular in origin
Absence of (N), upright P wave
associated with QRS complexes
QRS > 0.10 sec
T wave opposite in direction to QRS
Rate < 40 / min
Rate < 40 / min

Accelerated
Accelerated Idioventricular
Idioventricular Rhythm
Rhythm
Impulse ventricular in origin
Absence of (N), upright P wave
associated with QRS complexes
QRS > 0.10 sec
T wave opposite in direction to QRS
Rate = 40-120 / min
Rate = 40-120 / min

Accelerated
Accelerated Idioventricular
Idioventricular Rhythm
Rhythm
With 2 foci of ventricular activity

Intraventricular Conduction Delay

Supraventricular rhythm with
associated BBB

Wide QRS complexes

Agonal Rhythm
Extreme sinus bradycardia with irregular, idioventricular
rhythm and occasional atrial activity

Wolf Parkinson White Syndrome

Supraventricular rhythm with wide
QRS complex because of pre-excitation
Short or no PR segment followed by a
delta wave (slurred upstroke of QRS)

Wolf Parkinson White Syndrome

Pacemaker Rhythm
No P wave (ventricular impulse origin)
Wide QRS complex (>0.10 sec)
Pacemaker spike precede the wide
QRS complexes

Thank you