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Arrhythmia Recognition
Cardiac Conduction System ECG Components Electrical and Mechanical Events

LEFT
ATRIUM
Sinoatrial
Node
HIS Bundle
RIGHT ATRI-
UM

Left Bundle
Branch

Right Bundle
Branch LEFT
VENTRICLE
1 Small Square = 1 mm (0.1 mV) 1 Small Square = .04 sec (40 msec)
RIGHT
VENTRICLE VERTICAL 1 Large Square = 5 mm (0.5 mV) HORIZONTAL 1 Large Square = .2 sec (200 msec) Mid Atrial Isovolumic Ventricular Isovolumic
AXIS
2 Large Squares = 1 mV
AXIS
5 Large Squares = 1 sec (1000 msec)
Diastole Contraction Ventricular Ejection Ventricular
Contraction Relaxation

Sinus Rhythms Supraventricular Rhythms Conduction Defects

Normal Sinus Rhythm Premature Atrial Complexes PACs Atrial Tachycardia Right Bundle Branch Block

P Wave PR Interval QRS Characteristics

(in seconds) (in seconds)
Heart Rate Rhythm P Wave PR Interval QRS Before each QRS, 0.12 to 0.20 0.12 RSR in V1
(in seconds) (in seconds)
Heart Rate Rhythm P Wave PR Interval QRS identical
(in seconds) (in seconds)
60 100 bpm Regular Before each QRS, 0.12 to 0.20 < 0.12 140 250 bpm Regular Abnormal P before 0.12 to 0.20 < 0.12
identical Heart Rate Rhythm P Wave PR Interval QRS each QRS
(in seconds) (in seconds) (difcult to see) Left Bundle Branch Block
N/A Irregular Premature and 0.12 to 0.20 < 0.12
abnormal.
Sinus Arrhythmia May be hidden
Atrial Flutter

Premature Atrial Complex Isolated PAC

P Wave PR Interval QRS Characteristics

(in seconds) (in seconds)
Before each QRS, 0.12 to 0.20 0.12 QS or rS in V1 and V2
identical ST elevation

Heart Rate Rhythm P Wave PR Interval QRS Heart Rate Rhythm P Wave PR Interval QRS Pre-excitation Syndrome
(in seconds) (in seconds) Heart Rate Rhythm P Wave PR Interval QRS (in seconds) (in seconds)
Usually Irregular Before each QRS, 0.12 to 0.20 < 0.12 (in seconds) (in seconds) A: 240 350 bpm A: Regular Flutter (F) waves usu- N/A < 0.12
60 100 bpm identical N/A Irregular Premature and 0.12 to 0.20 < 0.12 V: Varies with V: Regular, ally the negative com-
abnormal. conduction ratio group beating ponent of the utter
May be hidden or variable wave in II, III, aVF and
positive in V1
Sinus Tachycardia
Premature Atrial Complexes (Atrial Bigeminy) Atrial Fibrillation
Every other beat is a PAC

P Wave PR Interval QRS Characteristics

(in seconds) (in seconds)
Heart Rate Rhythm P Wave PR Interval QRS Before each QRS, < 0.12 Usually > 0.10 Delta wave
(in seconds) (in seconds)
identical distorts initial QRS
> 100 bpm Regular Before each QRS, 0.12 to 0.20 < 0.12 Heart Rate Rhythm P Wave PR Interval QRS
identical (in seconds) (in seconds)
A: 350 650 bpm Irregular Absent N/A < 0.12 First-Degree AV Block
Heart Rate Rhythm P Wave PR Interval QRS V: Slow to rapid Fibrillatory (f) waves
(in seconds) (in seconds)
Sinus Bradycardia N/A Irregular Premature and 0.12 to 0.20 < 0.12
abnormal.
May be hidden Junctional Rhythm

Premature Atrial Complex with Aberrancy

P Wave PR Interval QRS Characteristics

(in seconds) (in seconds)
Before each QRS, > 0.20 < 0.12 Regular rhythm
Heart Rate Rhythm P Wave PR Interval QRS identical
(in seconds) (in seconds) Heart Rate Rhythm P Wave PR Interval QRS
< 60 bpm Regular Before each QRS, 0.12 to 0.20 < 0.12 (in seconds) (in seconds)
identical 40 60 bpm Regular Inverted in inferior < 0.12 < 0.12 Second-Degree AV Block Type I
leads; before, during
or after the QRS; (AV Wenckebach or Mobitz type I)
may be absent
Sinus Arrest or SA Block
P P P P P P

Accelerated Junctional Rhythm

Heart Rate Rhythm P Wave PR Interval QRS

(in seconds) (in seconds)
N/A Irregular Premature and 0.12 to 0.20 < 0.12
abnormal. Abnormal shape
May be hidden P Wave PR Interval QRS Characteristics
(in seconds) (in seconds)
Heart Rate Rhythm P Wave PR Interval QRS Conduction Increasingly < 0.12 QRS dropped in a
(in seconds) (in seconds) intermittent prolonged repeating pattern
40 100 bpm Irregular Identical before 0.12 to 0.20 < 0.12
each QRS.
P to P interval Nonconducted Premature Atrial Complex
may be xed before Heart Rate Rhythm P Wave PR Interval QRS Second-Degree AV Block Type II
and after the pause (in seconds) (in seconds) (Mobitz type II)
60 100 bpm Usually AV May be sinus P wave < 0.12 < 0.12
dissociation be- (AV dissociation)
cause of digitalis
toxicity
P Wave is buried in the T Wave.
NOTE: Notch is not present in other T Waves

Heart Rate Rhythm P Wave PR Interval QRS

Junctional Tachycardia
(in seconds) (in seconds) P Wave PR Interval QRS Characteristics
(in seconds) (in seconds)
N/A Irregular Premature and None Absent
abnormal. Sinus Usually normal Broad Some P waves
May be hidden and identical 0.12 are not conducted
(before and after a
blocked impulse)

Second-Degree AV Block 2:1 AV Block

Heart Rate Rhythm P Wave PR Interval QRS

(in seconds) (in seconds)
Usually Regular Inverted, absent or < 0.12 < 0.12
<140 bpm after QRS

P Wave PR Interval QRS Characteristics

(in seconds) (in seconds)
Sinus Normal or prolonged Narrow or broad 2:1 AV conduction

Third-Degree (Complete) AV Block

Arrhythmia Recognition (poster 1 of 2) Normal ECG Standards for Children by Age This poster includes Premature Ventricular Conduction, Pacemaker Lead
Placement, ST Segment Depression, Ventricular Rhythms, Pacemaker
This is part one of two posters to assist healthcare professionals in 01d 13d 37d 7 30 d 1 3 mo 3 6 mo 6 12 mo 13 y 35y 58y 8 12 y 12 16 y
Rhythms, Full Compensatory Pause and ECG Artifact. The ECG rhythm
recognizing basic arrhythmias. According to the Practice Standards Heart
Rate/Min
94 -155
(122)
91 - 158
(122)
90 - 166
(128)
106 - 182
(149)
120 - 179
(149)
105 - 185
(141)
108 - 169
(131)
89 - 152
(119)
73 - 137
(109)
65 - 133
(100)
62 - 130
(91)
60 - 120
(80) strips display lead II as the top waveform and lead V1 as the bottom
for Electrocardiographic Monitoring in Hospital Settings (Circulation. PR Interval 0.08 - 0.16 0.08 - 0.14 0.07 - 0.15 0.07 - 0.14 0.07 - 0.13 0.07 - 0.15 0.07 - 0.16 0.08 - 0.15 0.08 - 0.16 0.09 - 0.16 0.09 - 0.17 0.09 - 0.18 waveform. Classic examples are shown for each rhythm to provide basic
2004;110:2721-2746) in general, the mechanisms of arrhythmias are Lead II (0.107) (0.108) (0.102) (0.100) (0.098) (0.105) (0.106) (0.113) (0.119) (0.123) (0.128) (0.135) visualization and avoid complexities. The intended use of this poster is
the same in both adults and children. However, the ECG appearance of (Seconds) to compliment a text and/or course in addition to a reference guide for
the arrhythmias may differ due to developmental issues such as heart QRS Interval 0.02 - 0.07 0.02 - 0.07 0.02 - 0.07 0.02 - 0.08 0.02 - 0.08 0.02 - 0.08 0.03 - 0.08 0.03 - 0.08 0.03 - 0.07 0.03 - 0.08 0.04 - 0.09 0.04 - 0.09 arrhythmia recognition
size, baseline heart rate, sinus and AV node function, and automatic Lead V5 (0.05) (0.05) (0.05) (0.05) (0.05) (0.05) (0.05) (0.06) (0.06) (0.06) (0.06) (0.07)
The most common ECG rate, interval, and duration measurements are from the following publications: P Wave PR Interval QRS Characteristics
innervation. (Seconds)
Clinical Electrocardiography (Post Graduate Institute for Medicine). (in seconds) (in seconds)
All values 2nd 98th percentile; numbers in parentheses, means. Adapted from Pediatr Cardiol. 1979;1:123.
Understanding Electrocardiography (Mary Boudreau Conover). Normal but not related N/A Narrow or broad AV dissociation
ECG terminology and diagnostic criteria often vary from text to text and How to Quickly and Accurately Master Arrhythmia Interpretation (Dale Davis). to QRS
from one teacher to another. There are often several terms describing Principles of Clinical Electrocardiography (M. J. Goldman).
similar ndings (for example: Premature Atrial Contraction, Atrial Basic Dysrhythmias Interpretation and Management (Robert Huszar).
Premature Complex, Atrial Extrasystole, Supraventricular Ectopic Beat, An Introduction to Electrocardiography (Leo Shamroth).
etc.) It is important to correlate the ECG interpretation with the clinical Interpretation of Arrhythmias (Emanual Stein).
observation of the patient.

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