Guide to Rhythm Strip Interpretation using six-step method How to use this guide: when you see an unfamiliar rhythm, analyze each part separately, according to the six step method. Put your answers in writing, and then compare. Don’t leap to conclusion about the name of the rhythm until you have completed all the steps. If the strip is composed of two distinct rhythms, analyze each one separately. For more info send email to: Joeniemczura@gmail.com rhythm | Rate | P wave | PR interval | QRS width | Clinical significance | treatment | Sinus rhythm | 60- 100 | Upright in lead II | 0.12 -0.20 | .06 - .10 | None. Patient will live three minutes. | None. treat failure and assess Sa o2 | Sinus bradycardia | Below 60 | Precede each QRS, normal shape | normal | normal | Normal in young athletic individuals; common in early post-inferior M.I.; may precipitate CCF | Oxygen. check for hemodynamic impairment; if present, atropine first then pacemaker using bradycardia protocol, possibly dopamine drip | Sinus tachycardia | 100- 160 | Precedes each QRS, normal configuration | normal | normal | Increased sympathetic outflow; hypoxia; hemorrhage | Oxygen. Treat underlying cause, do not correct the rate if a definitive cause is left untreated | Pemature Atrial Contraction (PAC) | A single beat faster than base rate | Different from normal, may be buried in preceding QRS | May be slightly long or normal | Could be normal slightly aberrant | Occasional ones insignificant; may be precursor to atrial tachycardia | Sedation; with hold coffee and tea; check lytes (MG and K) digoxin or beta blockers may be used, rarely required | Supraventricular Tachycardia (SVT) | 140-160 | Takes some digging, sometimes difficult to find! | Variable according to category | normal | This is a catchall term for a family of rhythms. | If not hemodynamically impaired, assess cause, if hypotensive or c/o chest pain, do vagal maneuvers, digoxin, calan, cordioversion or adenosine | Atrial Fibrillation (AF) | 140-160 (ventricular response “irregularly irregular” | None identified, fib waves at 300+ per minute. | none | normal | May precipitate chock, CCF, or syncope depending on rate. Digoxin toxicity or hypokalemia. Check for valve problem and clot. “controlled” versus “uncontrolled” | Digoxin, calan, adenosine or dc cardioversion. Heparin or Coumadin to prevent stroke. Note: if patient is already on digoxin, rate may be 80 to 100. | Atrial Flutter | More regular than AF | F waves, no P waves, “sawtooth” | No P-R | normal | As above | As above - check digoxin levels. | Paroxysmal Atrial Tachycardia (PAT) | 40-60, comes in spurts | May be buried in preceding T wave | Usually normal | normal | Abrupt in start and end | Vagal maneuvers, hold digoxin if significant, adenosine | Sinus PauseSinus Arrest | Dramatically slower than base rate | Normal when they are present | None except “none in missing beats” | normal | May be symptomatic or not; may produce shock; may be a forerunner of asystole. | Use bradycardia protocol, assess carefully for symptoms and review history. anticipate pacemaker if frequent or symptomatic | Wandering Atrial Pacemaker | May occur at any rate | More than one shape | normal | normal | Atrial irritability | Check lytes, chiya consumption | Premature Junctionalcontractions | Ma y occur at any rate faster than the base rate | Upright, inverted or unidentifiable. | Sometimes a retrograde P | Usually normal, may be notched | Occasional ones insignificant. In order to count as Premature, they are usually a single beat added to normal sinus or some other rhythm. | Carefully evaluate to rule out PVCs (sometimes difficult to tell). |

Junctional rhythm | 60 (sometimes up to 80 but 60 is classic) | As above | If precedes QRS, will be short | Usually normal, wide or notched | Frequent indicator of re-perfusion during thrombolysis. May precipitate shock or CCF; see “PEA” | Doublecheck presence of a pulse if junctional rhythm appears after defibrillation. | First degree AV block | May be seen at any rate below 100; most frequently with bradycardia | normal | Longer than 0.20 seconds | normal | Most often a sign of drug toxicity, esp digoxin, quinine, or beta blocker | Observe for progression to some other type of block, esp if patient has had an inferior wall M.I.hold meds if significant | Second degree AV block, Mobitz I or “Wenckebach” | “regularly irregular” | normal | Get s progressively longer until a beat is “dropped” | normal | QRS complexes come in “clumps” | Usually none, hold digoxin | Second degree AV block, Mobitz II | Depends on degree of block | Normal. Two Ps for every QRS | Not all P’s are conducted; Ps without Qs. | Usually normal, check for BBBs | Ominous sign in acute M.I. – may precede ventricular standstill! | Oxygen, Atropine, pacemaker | Third degree AV block (complete block) | 40- 50 ( ventricular rate = 48) | normal | Ps and Qs are independent of each other | May be wide and aberrant; may be normal if escape focus is high in AV node. | Shock, syncope and angina may follow. Death may occur “kicking off bedclothes” due to (cold) sweat | Atropine, pacemaker, oxygen. Give lidocaine cautiously if PVCs occur, use atropine first | Premature ventricular Contractions (PVCs) | Faster than NSR ( or whatever base rhythm is) | Lost or buried in QRS | none | Wide and aberrant, T wave usually opposite. Has a compensatory pause. | May precede death, but also be insignificant. Must always be treated when patient has elevated cardiac enzymes | Oxygen. Treat CCF. If occurring with bradyarhythmia, use atropine. Otherwise lidocaine as per protocol. See note under third degree block. Check patient’s cardiac enzymes and 12-lead | Ventricular Tachycardia (VT) | 100- 250 | Not seen | none | Wide and aberrant; may be regular or irregular | Shock or syncope may occur, precedes VF! | Oxygen. CPR Check patient immediately! Prepare for cardioversion. Compare to SVT (wide vs narrow) | Ventricular Fibrillation (VF) | Rapid and disorganized | none | none | Wide irregular oscillations | Associated with death | Immediate defibrillation; CPR; 1.0 mg epinephrine. Start lidocaine drip if defib successful. | Ventricular Standstill | May be preceded by bradycardia then no activity | sometimes | None- infinity | No | Patient is clinically dead | CPR! Give atropine 1.0mg; “Code Blue” epinephrine 1.0 mg | asystole | No rate | no | No | Not applicable | Associated with death | Check electrodes and patient; rule out “fine VF” treat as for ventricular standstill. CPR! | Pulseless Electrical Activity | Frequently 40- 80 | Sometimes but not usually | No | May be normal, wide or aberrant | Frequently appears as a junctional rhythm, patient may have tamponade or ventricular rupture | Check pulses, prepare for pericardial tap, do CPRH.H.H.H.H.H. T.T.T.T.T. |