RHYTHM INTERPRETATION AND ITS MANAGEMENT

SINUS RHYTHMS

Normal Sinus Rhythm

It is also known as sinus rhythm. This rhythm is result when all the conduction pathways are working
normally and SA node act as dominant pacer triggering regular rate 60-100 beats per minute.

ECG Criteria

1. Heart Rate: 60-100bpm

2. Rhythm: Regular (both atrial and ventricular)
3. P waves: Upright and Uniform, each P followed by QRS
4. PR interval: 0.12 0.20 seconds
5. QRS width: 0.12 seconds.

Management

There is no management required for the normal sinus rhythm.

Sinus Bradycardia

It is characterized by a decrease in the heart rate less than 60 bpm due to the slowing of SA node leading
decrease in atrial depolarization.

ECG criteria
1. Heart rate: less than 60bpm
2. Rhythm: Atrial regular, Ventricular regular
3. P waves: Upright and uniform. Each P precedes every QRS compex
4. PR interval: 0.12 0.20 seconds
5. QRS width: 0.12 seconds

Management

Sinus Tachycardia

It is characterized by a rapid rate discharge from the SA node. The SA node is triggering at rate more than
100 with normal conduction pathway.

ECG criteria
1. Heart rate: more than 60bpm
2. Rhythm: Regular
 3. P waves: Upright and uniform. Each P precedes every QRS compex
4. PR interval: 0.12 0.20 seconds
5. QRS width: 0.12 seconds

Management

ATRIAL DYSRHYTHMIAS

Premature Atrial Contractions (PACs)

This rhythm presents with non sinus beats originated from left or right atrium as ectopic beat. The
Ectopic beat stimulates atrial depolarization but remaining conduction system is normal through AV node-
junction and downward into the bundle branches.

ECG criteria
1. Heart rate: Normal
2. Rhythm: Premature beat followed by regular rhythm
3. P waves: Premature atrial depolarization occurs before next normal P wave. Non Sinus P wave
may have different shape, peaked or buried with T wave.
4. PR interval: depending on origin of PAC it may be normal, shorter or longer.
5. QRS width: typically normal but may be prolonged if PAC is originated through ventricles.

Management

Atrial Fluter

It is results from faulty reentry of impulse within the atria. Atrial fluter represents sawtooth or picket
fence appearance. These flutter waves should not be confused with P waves. The AV node act as
protective mechanism by allowing few atrial depolarizations to pass through the bundle of his into
bundle branches and to the ventricles. When the ventricular rate is less than 100bpm then it is controlled
atrial flutter and if more than 100 than it is known as uncontrolled atrial flutter.

ECG criteria
1. Heart rate: atrial rate is 250-300 bpm. Ventricles rate varies according to AV node conduction.
2. Rhythm: Atrial regular, Ventricular may be regular or irregular
3. P waves: Absent, only flutter or saw tooth looking waveforms
4. PR interval: not applicable
5. QRS width: 0.12 second

Management

Atrial Fibrillation

The electrical activity is very fast but each impulse results in partial depolarization of atrial myocardium
rather than whole atrium results from multiple re-entry within the atria or from multiple ectopic foci.
ECG criteria
1. Heart rate: Atrial rate is 350-400bpm, ventricular rate varies.
2. Rhythm: Irregular
3. P waves: Absent
4. PR interval: not applicable
5. QRS width: 0.12 seconds

Management

JUNCTIONAL RHYTHMS

Junctional escape rhythm

This rhythm results from failure of SA node to initiate appropriate impulse because of conduction
disturbances between SA node and AV node. Te AV Junction act as pacemaker and trigger impulse at rate
of 40 to 60 bpm. If impulse generated from AV junction the atria may or may not be stimulated. The
electrical impulse must travel in backward direction to activate atria leading inverted P wave before or
after QRS complex.

ECG criteria
1. Heart rate: 40- 60bpm
2. Rhythm: Ventricular regular
3. P waves: May be absent or may occur before, during or after the QRS.
4. PR interval: None
5. QRS width: 0.12 seconds

Management

Junctional Tachycardia

It is characterized by greater rate from normal Junctional intrinsic rate 40-60bpm. It might resemble to
normal sinus rhythm but there will be no uniform P wave as SA node is not working and impulse is
generated from AV junction.

ECG criteria
1. Heart rate: 60-100bpm
2. Rhythm: Ventricular rhythm is regular
3. P waves: May be absent or may occur before, during or after the QRS.
4. PR interval: None
5. QRS width: 0.12 seconds

Management

ATRIOVENTRICULAR BLOCK
Atrioventricular blocks is also known as heart blocks and further categorized into three degrees.

First degree AV block

It represents basically interruption in impulse from atria to ventricles. Thus it is not an actual block rather
a delayed conduction of impulse.

ECG criteria
1. Heart rate: Varies
2. Rhythm: Regular
3. P waves: Upright and normal, proceeded with QRS complex
4. PR interval: None
5. QRS width: 0.12 seconds

Management

Second degree AV block

In second degree heart blocks all the impulses are not conducted through the AV node. The impulse
originates from SA node but conducted through AV node intermittently. It is of two types Mobitz I and
the other is called Type II.

Second degree Type I

It is characterized by progressive prolongation of the PR interval. The SA node triggers regularly in

normal pattern but there will be prolonged PR interval due to progressive delay in conduction through AV
node until there is one impulse is completely blocked.

ECG criteria
1. Heart rate: Atrial regular, ventricular rate is slightly slower
2. Rhythm: Atrial regular, Ventricular irregular.
3. P waves: Upright and normal. Some Ps are not followed by QRS complex
4. PR interval: progressively prolonged until one P waves not followed by a QRS complex. After the
blocked beat cycle starts again
5. QRS width: 0.12 seconds

Management

Second degree Type II

This refers to delayed conduction below the level of AV node. It has constant PR interval in every beat
having QRS complex.

ECG criteria
1. Heart rate: Atrial regular, ventricular rate is slower
2. Rhythm: Atrial regular, Ventricular irregular.
3. P waves: Upright and normal. Some Ps are not followed by QRS complex
 4. PR interval: the PR interval will be constant for conducted beats across the strip
5. QRS width: 0.12 seconds for conducted beats.

Management

Second degree Type III or complete heart block

It occurs when atrial contractions are normal but there is no electrical conduction to the ventricles. Then
ventricles generate their own trigger through Junctional escape mechanism from a foci within the
ventricles.

ECG criteria
1. Heart rate: Atrial is normal, ventricular rate is slower (40-60 from junction or 20-40 if from
ventricles)
2. Rhythm: regular P-P, And R-R but there is no association between two.
3. P waves: Upright and normal.
4. PR interval: No PR interval as there is no relation between P and QRS.
5. QRS width: 0.12 seconds if beat is by junction and > 0.12 seconds if paced by ventricle.

Management

VENTRICULAR RHYTHMS

Premature ventricular contractions

It represents the ventricular depolarization before the next sinus beat leading premature ventricular beat.

Unifocal PVCs: when PVC originates from single foci and has same morphology each time

Multiple PVCs: when there is multiple foci present to trigger ectopic beat.

ECG criteria
1. Heart rate: depends on underlying rhythm
2. Rhythm: irregular
3. P waves: no association of P waves with PVCs.
4. PR interval: Not applicable

5. QRS width: > 0.12 seconds wide and bizarre in appearance.

Management

Ventricular tachycardia

It is characterized by three or more consecutive PVCs in a row at a rate greater than 100 bpm. The hearts
normal pacemaker function is taken up by ventricles leading widened QRS complex followed by large T
wave in opposite direction of QRS complex. It may be monomorphic when all the QRS complexes with
the same pattern or polymorphic having varying QRS shapes during tachycardia.
ECG criteria
1. Heart rate: 100-250 bpm
2. Rhythm: Ventricular rhythm regular.
3. P waves: P waves may or may not be present. If present not associated with QRS complex
4. PR interval: Not applicable
5. QRS width: > 0.12 seconds wide and bizarre in appearance.

Management

Ventricular Fibrillation

It results from rapid electrical stimulation of ventricles leading disorganized ventricular depolarization.
Depending upon amplitude of waveforms it is classified as coarse and fine VF.

Coarse VF: usually waves are greater than 3mm in height and easily recognizable.

Fine VF: Having amplitude less than 3mm and resemble to asystole.

ECG criteria
1. Heart rate: none
2. Rhythm: chaotic recording
3. P waves: none
4. PR interval: Not applicable
5. QRS width: Not applicable.

Management

Asystole

There is complete absence of electrical activity presenting straight line on ECG, As there will be no
depolarization.

ECG criteria
1. Heart rate: None
2. Rhythm: None.
3. P waves: None
4. PR interval: None
5. QRS width: None.

Management