Those nasty rhythm problems

• 1. Rate:
  • Look at the rate first..
  • You can use the blocks on the strip to count.. (0.20 secs). 1 block between QRS complexes is 300 beats a min, 2 blocks is 150, 3 is 100, then 75, 60, 50..
    • Rate over 100 = tachycardia
    • Rate under 60 = bradycardia

• 2. Rhythm:
  • Next look at the rhythm,
    • A regular rhythm =normal rhythm or a brady or tachy as above.
    • A regular rhythm with irregular beats = premature beats (either PAC's or PVC's)
    • An irregularly irregular rhythm = chaotic rhythm, often Atrial fibrillation or Ventricular Fibrillation, or frequent multifocal PVC's.

• 3. P wave:
  • Is there a P wave before each QRS?
  • Is there only one P wave per QRS?
  • Is it always the same configuration?
  • Is the distance between the P and the QRS constant?
  • Is the distance between a P and a QRS is .10 to .20 seconds?
  • P waves not present:
    • No P, Narrow QRS, normal or slow, Regular = Junctional
    • No P, Narrow QRS, fast or slow, Irregular = Atrial fib
    • No P, Wide QRS, Slow, Regular= idioventricular
    • No P, Wide QRS Fast, basically Regular =V Tach
  • 1 P per QRS
    • 1 P wave, Narrow QRS, Regular, normal rate = NSR
    • 1 P wave present but with different configurations: = wandering pacer
  • 1 P wave longer than .20sec:
    • P with every QRS= 1st degree AV Block.
    • PR constant with dropped QRS's= 2nd degree heart Block
    • with progressive PR prolongation =2nd degree AV Block, Wenkebach (type I)
    • No relationship between P's and QRS's = 3rd degree AV block
  • More than 1 P wave:
    • irregularly irregular = Atrial Fib
    • Many P's same configuration, Regular = Atrial flutter (P Rate often 300 and QRS rate might be 150 (2:1), or 100 (3:1))
    • P's grouped with regular R to R's = 2nd degree Block, type 11
    • Increasing PR intervals, Basically regular with dropped QRS's =2nd degree block type 1, Wenkebach
    • No relationship between P's and QRS's = 3rd degree Block, Complete Heart Block

• 4. QRS:
  • Narrow or wide(.06 .10)?
  • Regular?
  • Rate
  • P wave preceding each QRS?
  • Narrow
    • Narrow,Regular, fast, P with every QRS = sinus Tachy, rate greater than 150= SVT (Supraventricular Ventricular Tachycardia)
    • Narrow, Regular, slow, P with every QRS = sinus Brady
  • Mixed narrow and wide
    • Mixed narrow and wide, regular wide beats =unifocal PVC's
    • Mixed narrow and wide, irregular wide beats = multifocal PVC's
  • Wide
    • Wide, Regular, slow or normal rate, P per QRS = BBB
    • Wide,regular, fast, P per QRS = ST or SVT with aberrancy
    • Wide, regular, with no relationship between P and QRS =3rd degree AVBlock
    • Wide, regular, slow =idioventricular
    • Wide, regular, Fast = V Tach

• 5. QT/T wave abnormality:
  • ST depression = myocardial ischemia
  • ST elevation = myocardial injury
  • Prolonged QT with flat T waves = hypokalemiaAVBlock
  • Early Peaked T waves = hyperkalemia.

• 6. No P's or QRS's (as an afterthought):
  • Completely irratic = V fib
  • Straight line = asystole