rate for normal sinus rhythm
regular rhythm
rate 60-100 bpm
upright P-wave in Lead II
Sinus Bradycardia
SR < 60 bpm
Sinus Tachycardia
SR > 100 bpm
Sinus Arrhythmia
irregular regular sinus rhythm between 60-100 bpm
varies with respiration
inhale = faster
exhale = slower
examples of sinus rhythms
Sinus Rhythm
Sinus Bradycardia
Sinus Tachycardia
Sinus Arrhythmia
Sinus Rhythm
Normal Sinus Rhythm
Normal Sinus Rhythm
Sinus Bradycardia
Sinus Bradycardia
Sinus Bradycardia
Sinus Tachycardia
Sinus Tachycardia
Sinus Arrhythmia
Sinus Arrhythmia and Bradycardia
bradycardiac and sinus arrhythmia
supraventricular rhythms are
above the AV NODE
Heart blocks are at
at the AV NODE
ventricular rhythms are
below the AV node
Supraventricular Arrhythmias
electrical impulse originates at or above the AV node
Atrial Fibrillation
Atrial Flutter
Paroxysmal supraventricular Tachycardia
Junctional Rhythms
Wandering Atrial Pacemaker
Multifocal Atrial Tachycardia
Ectopic Atrial Tachycardia
A FIB
A FIB
A FIB WITH RAPID VENTRICULAR RESPONSE
(>120)
A FIB WITH RAPID VENTRICULAR RATE
A FIB CONTROLLED
A FLUTTER
A FLUTTER WITH VARIABLE AV CONDUCTION
A FLUTTER
A FLUTTER WITH 4:1 AV CONDUCTION
A FLUTTER WITH 2:1 AV CONDUCTION
PSVT
PSVT
COMMON CAUSES OF REGULAR SVT
without signs of normal atrial activity
sinus tachycardia
atrial flutter
PSVT
PSVT
JUNCTIONAL RHYTHM
JUNCTIONAL RHYTHM (ESCAPE RHYTHM)
ACCELERATED JUNCTIONAL RHYTHM
ACCELERATED JUNCTIONAL RHYTHM
ACCELERATED JUNCTIONAL RHYTHM
junctional rhythm
junctional tachycardia
JUNCTIONAL TACHYCARDIA
JUNCTIONAL TACHYCARDIA
Retrograde (negative) P-waves (before, during, or after QRS complex)
JUNCTIONAL ESCAPE BEAT
Wandering Atrial Pacemaker (WAP)
Wandering Atrial Pacemaker (WAP)
Multifocal Atrial Tachycardia (MAT)
Multifocal Atrial Tachycardia (MAT)
Ectopic Atrial Tachycardia (EAT)
Premature Beats
QRS occurs (early) before next expected beat
Premature Atrial Contraction (PAC) Premature Junctional Contraction (PJC) Premature Ventricular Contraction (PVC)
Premature Atrial Contraction (PAC)
Premature Atrial Contraction (PAC)
Premature Atrial Contraction (PAC)
Sinus Bradycardia with PAC
PAC hidden in preceding T wave distorting contour
(increased voltage)
SR with 1 nonconducted PAC
PAC hidden in preceding T wave distorting contour
Sinus Tachycardia with 2 nonconducted PACs
Premature Junctional Contraction (PJC)
SR with Premature Junctional Contraction (PJC)
Premature Ventricular Contraction (PVC)
�PVCs have the following features:
Broad QRS complex (? 120 ms) w/ abnormal morphology Premature: occurs earlier than expected for the next sinus impulse Discordant ST segment & T wave changes
Usually followed by a full compensatory pause
Retrograde capture of the atria may or may not occu
PVCs may be either:
Unifocal: Arising from a 1 ectopic focus; each PVC is identical Multifocal: Arising from 2 or more ectopic foci; multiple QRS
morphologies
PVCs often occur in repeating patterns:
Bigeminy
TRIGEMINY
QUADRIGEMINY
COUPLET
TRIPLET
bigeminy
every other beat is a PVC
trigeminy
every 3rd beat is a PVC
quadrigeminy
every 4th beat is a PVC
couplet
2 consecutive PVCs
triplet
3 consecutive PVCs
PAC VS. PVC
PAC: non-compensatory pause (atrial rhythm returns out of sync) PVC: compensatory pause (atrial rhythm returns on time)
Sinus Rhythm with PVC
SR w/ multifocal PVCs
SR w/ frequent PVCs in bigeminy
ST w/ frequent PVCs in quadrigeminy
VENTRICULAR ESCAPE BEAT
Sinoatrial (SA) Pauses
Unhealthy SA node
sinus exit block
sinus arrest
sinus block
normal sinus block
sinus arrest
Normal Sinus Rhythm (NSR) with Sinus Arrest
Sick Sinus Syndrome (SSS)
Dysfunction of the SA node
Can be frequent long sinus pauses & Bradycardia
Or a fast rhythm like AFib & alternating episodes of long sinus pauses
AKA: Tachy Brady Syndrome
1st Degree Heart Block
SR with 1st degree AV block
2nd Degree Heart Block (Mobitz I) AKA: Wenckebach
SR with 2nd degree AV block (Mobitz I)
Wenckebach
2nd Degree Heart Block (Mobitz II)
SR with 2nd degree AV block (Mobitz II)
Causes of Grouped Beats ("Clumps")
1.Premature contractions
2.2nd degree AV block
2nd degree AV block
Mobitz I (Wenckebach) or Mobitz II
Premature contractions
Clumps of 2? think bigeminy Clumps of 3? think trigeminy
Anytime the rhythm is irregular what should you look for
regular irregularity (clumps)!
3rd degree (complete) heart block
3rd degree AV block
if there are as many P waves as QRS waves, but they are dissociate
AV dissociation, NOT 3rd �
HB
Ventricular Rhythms
Wide QRS
Idioventricular Rhythm
Ventricular Tachycardia
Ventricular Fibrillation
Idioventricular Rhythm
Accelerated Idioventricular Rhythm (AIVR)
Ventricular Tachycardia (VT)
Ventricular Flutter (VFlutter)
Polymorphic Ventricular Tachycardia (PVT) Torsades de Pointes (TdP)
Idioventricular Rhythm (IVR)
IVR
AIVR
Accelerated Idioventricular Rhythm (AIVR)
Accelerated Idioventricular Rhythm (AIVR)
Ventricular Tachycardia (VT)
Ventricular Tachycardia (VT)
Brugada's sign:
R wave to bottom of S wave ?0.10 sec (2.5 little boxes)
Josephson's sign:
Small notching at low point of S wave (atrial beat)
Atrioventricular dissociation (visible P-waves cause notching)
VT RED: BRUGADA'S SIGN BLUE: JOSEPHSON'S SIGN
Wide-complex Tachycardia (WCT)
VT
V FLUTTER
Torsade de Pointes (TdP)
Torsade de Pointes (TdP)
Torsade de Pointes (TdP)
V FIB
V FIB
V FIB
Agonal rhythm (dying heart)
Ventricular Standstill
Normal PR segment
0.12 - 0.20 seconds
3-5 little boxes
less than 1 big box
Normal QRS Complex
0.04 - 0.10 seconds
1 - 2.5 little boxes
less than 1/2 of a big box
Normal QT segment
half of the R-R interval if the rate is less than 100 bpm
Heart rate for Atrial fibrillation with slow ventricular response
less than 60 bpm
Heart rate for Atrial fibrillation with controlled response
70 - 110 bpm
Heart rate for Afib with rapid ventricular response
greater than 120 bpm
rate for normal sinus rhythm
regular rhythm
rate 60-100 bpm
upright P-wave in Lead II
Sinus Bradycardia
SR < 60 bpm
Sinus Tachycardia
SR > 100 bpm
Sinus Arrhythmia
irregular regular sinus rhythm between 60-100 bpm
varies with respiration
inhale = faster
exhale = slower
examples of sinus rhythms
Sinus Rhythm
Sinus Bradycardia
Sinus Tachycardia
Sinus Arrhythmia
Sinus Rhythm
Normal Sinus Rhythm
Normal Sinus Rhythm
Sinus Bradycardia
Sinus Bradycardia
Sinus Bradycardia
Sinus Tachycardia
Sinus Tachycardia
Sinus Arrhythmia
Sinus Arrhythmia and Bradycardia
bradycardiac and sinus arrhythmia
supraventricular rhythms are
above the AV NODE
Heart blocks are at
at the AV NODE
ventricular rhythms are
below the AV node
Supraventricular Arrhythmias
electrical impulse originates at or above the AV node
Atrial Fibrillation
Atrial Flutter
Paroxysmal supraventricular Tachycardia
Junctional Rhythms
Wandering Atrial Pacemaker
Multifocal Atrial Tachycardia
Ectopic Atrial Tachycardia
A FIB
A FIB
A FIB WITH RAPID VENTRICULAR RESPONSE
(>120)
A FIB WITH RAPID VENTRICULAR RATE
A FIB CONTROLLED
A FLUTTER
A FLUTTER WITH VARIABLE AV CONDUCTION
A FLUTTER
A FLUTTER WITH 4:1 AV CONDUCTION
A FLUTTER WITH 2:1 AV CONDUCTION
PSVT
PSVT
COMMON CAUSES OF REGULAR SVT
without signs of normal atrial activity
sinus tachycardia
atrial flutter
PSVT
PSVT
JUNCTIONAL RHYTHM
JUNCTIONAL RHYTHM (ESCAPE RHYTHM)
ACCELERATED JUNCTIONAL RHYTHM
ACCELERATED JUNCTIONAL RHYTHM
ACCELERATED JUNCTIONAL RHYTHM
junctional rhythm
junctional tachycardia
JUNCTIONAL TACHYCARDIA
JUNCTIONAL TACHYCARDIA
Retrograde (negative) P-waves (before, during, or after QRS complex)
JUNCTIONAL ESCAPE BEAT
Wandering Atrial Pacemaker (WAP)
Wandering Atrial Pacemaker (WAP)
Multifocal Atrial Tachycardia (MAT)
Multifocal Atrial Tachycardia (MAT)
Ectopic Atrial Tachycardia (EAT)
Premature Beats
QRS occurs (early) before next expected beat
Premature Atrial Contraction (PAC) Premature Junctional Contraction (PJC) Premature Ventricular Contraction (PVC)
Premature Atrial Contraction (PAC)
Premature Atrial Contraction (PAC)
Premature Atrial Contraction (PAC)
Sinus Bradycardia with PAC
PAC hidden in preceding T wave distorting contour
(increased voltage)
SR with 1 nonconducted PAC
PAC hidden in preceding T wave distorting contour
Sinus Tachycardia with 2 nonconducted PACs
Premature Junctional Contraction (PJC)
SR with Premature Junctional Contraction (PJC)
Premature Ventricular Contraction (PVC)
�PVCs have the following features:
Broad QRS complex (? 120 ms) w/ abnormal morphology Premature: occurs earlier than expected for the next sinus impulse Discordant ST segment & T wave changes
Usually followed by a full compensatory pause
Retrograde capture of the atria may or may not occu
PVCs may be either:
Unifocal: Arising from a 1 ectopic focus; each PVC is identical Multifocal: Arising from 2 or more ectopic foci; multiple QRS
morphologies
PVCs often occur in repeating patterns:
Bigeminy
TRIGEMINY
QUADRIGEMINY
COUPLET
TRIPLET
bigeminy
every other beat is a PVC
trigeminy
every 3rd beat is a PVC
quadrigeminy
every 4th beat is a PVC
couplet
2 consecutive PVCs
triplet
3 consecutive PVCs
PAC VS. PVC
PAC: non-compensatory pause (atrial rhythm returns out of sync) PVC: compensatory pause (atrial rhythm returns on time)
Sinus Rhythm with PVC
SR w/ multifocal PVCs
SR w/ frequent PVCs in bigeminy
ST w/ frequent PVCs in quadrigeminy
VENTRICULAR ESCAPE BEAT
Sinoatrial (SA) Pauses
Unhealthy SA node
sinus exit block
sinus arrest
sinus block
normal sinus block
sinus arrest
Normal Sinus Rhythm (NSR) with Sinus Arrest
Sick Sinus Syndrome (SSS)
Dysfunction of the SA node
Can be frequent long sinus pauses & Bradycardia
Or a fast rhythm like AFib & alternating episodes of long sinus pauses
AKA: Tachy Brady Syndrome
1st Degree Heart Block
SR with 1st degree AV block
2nd Degree Heart Block (Mobitz I) AKA: Wenckebach
SR with 2nd degree AV block (Mobitz I)
Wenckebach
2nd Degree Heart Block (Mobitz II)
SR with 2nd degree AV block (Mobitz II)
Causes of Grouped Beats ("Clumps")
1.Premature contractions
2.2nd degree AV block
2nd degree AV block
Mobitz I (Wenckebach) or Mobitz II
Premature contractions
Clumps of 2? think bigeminy Clumps of 3? think trigeminy
Anytime the rhythm is irregular what should you look for
regular irregularity (clumps)!
3rd degree (complete) heart block
3rd degree AV block
if there are as many P waves as QRS waves, but they are dissociate
AV dissociation, NOT 3rd �
HB
Ventricular Rhythms
Wide QRS
Idioventricular Rhythm
Ventricular Tachycardia
Ventricular Fibrillation
Idioventricular Rhythm
Accelerated Idioventricular Rhythm (AIVR)
Ventricular Tachycardia (VT)
Ventricular Flutter (VFlutter)
Polymorphic Ventricular Tachycardia (PVT) Torsades de Pointes (TdP)
Idioventricular Rhythm (IVR)
IVR
AIVR
Accelerated Idioventricular Rhythm (AIVR)
Accelerated Idioventricular Rhythm (AIVR)
Ventricular Tachycardia (VT)
Ventricular Tachycardia (VT)
Brugada's sign:
R wave to bottom of S wave ?0.10 sec (2.5 little boxes)
Josephson's sign:
Small notching at low point of S wave (atrial beat)
Atrioventricular dissociation (visible P-waves cause notching)
VT RED: BRUGADA'S SIGN BLUE: JOSEPHSON'S SIGN
Wide-complex Tachycardia (WCT)
VT
V FLUTTER
Torsade de Pointes (TdP)
Torsade de Pointes (TdP)
Torsade de Pointes (TdP)
V FIB
V FIB
V FIB
Agonal rhythm (dying heart)
Ventricular Standstill
Normal PR segment
0.12 - 0.20 seconds
3-5 little boxes
less than 1 big box
Normal QRS Complex
0.04 - 0.10 seconds
1 - 2.5 little boxes
less than 1/2 of a big box
Normal QT segment
half of the R-R interval if the rate is less than 100 bpm
Heart rate for Atrial fibrillation with slow ventricular response
less than 60 bpm
Heart rate for Atrial fibrillation with controlled response
70 - 110 bpm
Heart rate for Afib with rapid ventricular response
greater than 120 bpm