Atrial & Junctional Dysrhythmias - Miami County EMS · Atrial & Junctional Dysrhythmias Atrial zPremature Atrial ... Not a common dysrhythmia. ... atrial fibrillation or flutter z

Atrial & Junctional Atrial & Junctional DysrhythmiasDysrhythmias

Atrial & Junctional DysrhythmiasAtrial & Junctional Dysrhythmias

AtrialAtrialPremature Atrial Premature Atrial ComplexComplexWandering Atrial Wandering Atrial PacemakerPacemakerAtrial Tachycardia Atrial Tachycardia (ectopic)(ectopic)Multifocal Atrial Multifocal Atrial TachycardiaTachycardiaAtrial FlutterAtrial FlutterAtrial FibrillationAtrial Fibrillation

JunctionalJunctionalJunctional Escape Junctional Escape RhythmRhythmPremature Junctional Premature Junctional ComplexComplexJunctional TachycardiaJunctional TachycardiaAccelerated Junctional Accelerated Junctional RhythmRhythmAV Nodal ReAV Nodal Re--entrant entrant Tachycardia (PSVT)Tachycardia (PSVT)

Atrial & Junctional vs. SA Node Atrial & Junctional vs. SA Node

Origin of the pacemaker site is at or above Origin of the pacemaker site is at or above the AV junction but is not the SA Nodethe AV junction but is not the SA Node

Single Atrial siteSingle Atrial siteMultiple atrial sitesMultiple atrial sitesAV JunctionAV Junction

Common CharacteristicsCommon CharacteristicsNarrow QRSNarrow QRSWithout regular, typical appearing, discernible P Without regular, typical appearing, discernible P waveswavesRegular or Irregular RhythmRegular or Irregular Rhythm

Premature Atrial Complex (PAC)Premature Atrial Complex (PAC)

PAC PAC -- Ectopic beat from the AtriaEctopic beat from the Atriaearlier than expectedearlier than expected

ItIt’’s a complex, not a rhythm!s a complex, not a rhythm!Assess the underlying rhythm firstAssess the underlying rhythm first



CausesCausesIdiopathicIdiopathicCaffeine, tobacco, alcoholCaffeine, tobacco, alcoholStress, Emotion, InfectionStress, Emotion, InfectionDigitalis toxicityDigitalis toxicityHypoxiaHypoxiaCongestive failureCongestive failureIncreased sympathetic toneIncreased sympathetic tone

Premature Atrial Complex (PAC)Premature Atrial Complex (PAC)CharacteristicsCharacteristics

Heart Rate:Heart Rate: dependent on the underlying rhythmdependent on the underlying rhythmRhythmRhythm: irregular if PACs are present; underlying rhythm : irregular if PACs are present; underlying rhythm may be regularmay be regularPacemakerPacemaker SiteSite: ectopic site in the atria; underlying : ectopic site in the atria; underlying rhythm has its own pacemaker siterhythm has its own pacemaker siteP WavesP Waves: earlier than next expected P wave; positive in : earlier than next expected P wave; positive in lead II; may not look like other P waves presentlead II; may not look like other P waves presentPP--R IntervalR Interval: usually normal for the PAC: usually normal for the PACRR--R IntervalR Interval: unequal since PACs present: unequal since PACs presentQRS ComplexQRS Complex: usually narrow: usually narrowP to QRSP to QRS: usually one to one relationship: usually one to one relationship

Analyze the RhythmAnalyze the Rhythm


CharacteristicsCharacteristicsPaired Ectopic Beats referred to as coupletPaired Ectopic Beats referred to as coupletAlternating Ectopic Beat referred to as Bigeminy, Alternating Ectopic Beat referred to as Bigeminy, Trigeminy, or QuadrigeminyTrigeminy, or Quadrigeminy

e.g. Atrial Bigeminy or Ventricular Bigeminye.g. Atrial Bigeminy or Ventricular Bigeminy

May not always result in ventricular conductionMay not always result in ventricular conduction““Blocked PACBlocked PAC”” or or ““NonNon--conducted PACconducted PAC””

No compensatory pause in PACNo compensatory pause in PACCompensatory vs. Noncompensatory PauseCompensatory vs. Noncompensatory Pause

Compensatory vs Compensatory vs NoncompensatoryNoncompensatory PausePause

Compare the distance between 3 normal beatsCompare the distance between 3 normal beatsNoncompensatoryNoncompensatory

the normal beat following the premature complex occurs the normal beat following the premature complex occurs before it was expected (the distance not the same)before it was expected (the distance not the same)

CompensatoryCompensatorythe normal beat following the premature complex occurs the normal beat following the premature complex occurs when expected (the distance is the same)when expected (the distance is the same)

The most common cause for aThe most common cause for apause is a nonpause is a non--conducted PAC.conducted PAC.


Premature Atrial Complex (PAC)Premature Atrial Complex (PAC)ManagementManagement

Usually not clinically significantUsually not clinically significanttreat underlying causetreat underlying cause

Frequent PACs may indicated enhanced Frequent PACs may indicated enhanced automaticity of atria or reentry mechanismautomaticity of atria or reentry mechanism

may warn of or initiate supraventricular arrhythmias may warn of or initiate supraventricular arrhythmias such as atrial tachycardia, atrial flutter, atrial such as atrial tachycardia, atrial flutter, atrial fibrillation or PSVTfibrillation or PSVTif nonconducted PACs are frequent and HR < 50, if nonconducted PACs are frequent and HR < 50, treat as bradycardiatreat as bradycardiaPACs may be wide (aberrant conduction) and must PACs may be wide (aberrant conduction) and must be differentiated form PVCsbe differentiated form PVCs

Wandering Atrial PacemakerWandering Atrial Pacemaker

PathophysiologyPathophysiologyshifting of pacemaker focus from one to another shifting of pacemaker focus from one to another within the atrial tissuewithin the atrial tissueMay be associated with ischemic disease involving May be associated with ischemic disease involving the sinus node or an inflammatory state (e.g. the sinus node or an inflammatory state (e.g. rheumatic fever)rheumatic fever)May occur without any finding of diseaseMay occur without any finding of disease


CharacteristicsCharacteristicsHeart Rate:Heart Rate: usually 60usually 60--100 bpm100 bpmRhythmRhythm: irregularly irregular (one of three): irregularly irregular (one of three)PacemakerPacemaker SiteSite: variable, all within the atria : variable, all within the atria including SA nodeincluding SA nodeP WavesP Waves: variable including normal appearing P : variable including normal appearing P waveswavesPP--R IntervalR Interval: unequal, varies: unequal, variesRR--R IntervalR Interval: unequal, varies: unequal, variesQRS ComplexQRS Complex: usually narrow: usually narrowP to QRSP to QRS: usually one to one relationship: usually one to one relationship


ManagementManagementECG rhythm generally does not require treatmentECG rhythm generally does not require treatmentUnderlying cause may require treatmentUnderlying cause may require treatment


Multifocal Atrial TachycardiaMultifocal Atrial Tachycardia

PathophysiologyPathophysiologySame as WAP just faster than 100 bpmSame as WAP just faster than 100 bpmAn uncommon ECG rhythmAn uncommon ECG rhythmUsually seen in someone with COPD or Usually seen in someone with COPD or severe systemic disease (e.g. sepsis, shock)severe systemic disease (e.g. sepsis, shock)


CharacteristicsCharacteristicsHeart Rate:Heart Rate: >100 bpm>100 bpmRhythmRhythm: irregularly irregular (one of three): irregularly irregular (one of three)PacemakerPacemaker SiteSite: variable, all within the atria : variable, all within the atria including SA nodeincluding SA nodeP WavesP Waves: variable including normal appearing P : variable including normal appearing P waveswavesPP--R IntervalR Interval: unequal, varies: unequal, variesRR--R IntervalR Interval: unequal, varies: unequal, variesQRS ComplexQRS Complex: usually narrow: usually narrowP to QRSP to QRS: one to one relationship: one to one relationship



ManagementManagementTreated like Supraventricular TachycardiaTreated like Supraventricular TachycardiaBe alert to signs of heart failureBe alert to signs of heart failure

Tachycardia Management Tachycardia Management OverviewOverview

If If Unstable Unstable : : Immediate Synchronized Immediate Synchronized CardioversionCardioversion

If Stable:If Stable:IV/OIV/O22/Monitor/12 lead ECG/Monitor/12 lead ECGIdentify Rhythm using 12 lead if necessaryIdentify Rhythm using 12 lead if necessaryDrug therapyDrug therapyIf drugs fail, then synchronized cardioversionIf drugs fail, then synchronized cardioversion

Tachycardia: Narrow ComplexTachycardia: Narrow Complex

Primary/Secondary ABCDPrimary/Secondary ABCDVagal maneuversVagal maneuversAdenosine 6 mg rapid IV push, with flushAdenosine 6 mg rapid IV push, with flush

Repeat with 12 mg rapid IV push with flushRepeat with 12 mg rapid IV push with flush

Other ConsiderationsOther Considerationsamiodarone 150 mg slow IV (15 mg/min)amiodarone 150 mg slow IV (15 mg/min)diltiazemdiltiazem 0.25 mg/kg slow IV 0.25 mg/kg slow IV synchronized cardioversionsynchronized cardioversion

Atrial FlutterAtrial FlutterSignatureSignature

““Saw toothSaw tooth”” baselinebaselineCommonly occurs in multiplesCommonly occurs in multiples

300, 300, 150150, 75, 75based on degree of AV blockbased on degree of AV block

Atrial FlutterAtrial Flutter

Atrial FlutterAtrial FlutterCausesCauses

Myocardial ischemiaMyocardial ischemiaHypoxiaHypoxiaCHFCHFCOPD (cor pulmonale)COPD (cor pulmonale)HyperthyroidismHyperthyroidismDigitalis toxicityDigitalis toxicity

Not a common dysrhythmiaNot a common dysrhythmia

Atrial FlutterAtrial FlutterCharacteristicsCharacteristics

Heart Rate:Heart Rate: usually multiples usually multiples -- 300, 150, 75300, 150, 75RhythmRhythm: usually regular except with variable AV : usually regular except with variable AV blockblockPacemakerPacemaker SiteSite: atrial site: atrial siteP WavesP Waves: No P waves; Flutter (F) waves: No P waves; Flutter (F) wavesPP--R IntervalR Interval: not applicable: not applicableRR--R IntervalR Interval: usually equal except with variable AV : usually equal except with variable AV blockblockQRS ComplexQRS Complex: usually narrow: usually narrowP to QRSP to QRS: not applicable: not applicable


Atrial Fibrillation (AAtrial Fibrillation (A--Fib)Fib)

SignatureSignatureIrregularly irregularIrregularly irregularNo organized atrial activityNo organized atrial activity

TypesTypesAA--Fib with uncontrolled ventricular response Fib with uncontrolled ventricular response (rate > 100, usually 160(rate > 100, usually 160--180)180)AA--Fib with controlled ventricular responseFib with controlled ventricular response(rate < 100, usually 60(rate < 100, usually 60--70)70)

Atrial Fibrillation (AAtrial Fibrillation (A--Fib)Fib)

Atrial FibrillationAtrial FibrillationCharacteristicsCharacteristics

Heart Rate:Heart Rate: atrial rate may be very fast, avg of 400 atrial rate may be very fast, avg of 400 bpm; variable ventricular ratebpm; variable ventricular rateRhythmRhythm: irregularly irregular: irregularly irregularPacemakerPacemaker SiteSite: multiple atrial sites: multiple atrial sitesP WavesP Waves: No P waves; fibrillation (f) waves: No P waves; fibrillation (f) wavesPP--R IntervalR Interval: not applicable: not applicableRR--R IntervalR Interval: usually unequal : usually unequal QRS ComplexQRS Complex: usually narrow: usually narrowP to QRSP to QRS: not applicable: not applicable


Atrial FibrillationAtrial FibrillationCausesCauses

Myocardial ischemiaMyocardial ischemiaHypoxiaHypoxiaCHFCHFCOPD (cor pulmonale)COPD (cor pulmonale)HyperthyroidismHyperthyroidismDigitalis toxicityDigitalis toxicityIdiopathicIdiopathic

Atrial FibrillationAtrial Fibrillation

PresentationPresentationParoxysmalParoxysmalAcuteAcuteChronicChronic

Atrial FibrillationAtrial Fibrillation

ComplicationsComplicationsLoss of atrial kickLoss of atrial kickThrombus formationThrombus formationEmboliEmboli

Tachycardia: A.fib/A. flutterTachycardia: A.fib/A. flutter

Primary/Secondary ABCDPrimary/Secondary ABCDAssess for WPW Assess for WPW –– Delta waveDelta wave

No WPWNo WPWCalcium channel blockersCalcium channel blockers

WPWWPWamiodarone 150 mg slow IV (15 mg/min)amiodarone 150 mg slow IV (15 mg/min)

Atrial Fib/Flutter TreatmentAtrial Fib/Flutter TreatmentRapid Response/Stable with SymptomsRapid Response/Stable with Symptoms

Oxygen, Monitor, IVOxygen, Monitor, IVVagal maneuvers (if needed as a diagnostic tool)Vagal maneuvers (if needed as a diagnostic tool)No WPWNo WPW

DiltiazemDiltiazem, 0.25 mg/kg slow IV over 2 min, may repeat i15 , 0.25 mg/kg slow IV over 2 min, may repeat i15 min at 0.35 mg/kg slow IV min at 0.35 mg/kg slow IV

WPWWPWamiodarone 150 mg slow IV (15 mg/min)amiodarone 150 mg slow IV (15 mg/min)

Atrial Fib/Flutter TreatmentAtrial Fib/Flutter TreatmentRapid Response/UnstableRapid Response/Unstable

Oxygen, Monitor, IVOxygen, Monitor, IVSedateSedateCardioversionCardioversionConsider anticoagulation firstConsider anticoagulation first

Atrial Fib/Flutter TreatmentAtrial Fib/Flutter Treatment

Slow Response/Unstable (usually occurs in Slow Response/Unstable (usually occurs in AA--Flutter)Flutter)

Oxygen, Monitor, IVOxygen, Monitor, IVAtropineAtropinePacemakerPacemakerDopamine or epinephrine infusionDopamine or epinephrine infusion

Atrial Fib/Flutter TreatmentAtrial Fib/Flutter Treatment

Normal (controlled) RateNormal (controlled) RateOxygen, Monitor, IVOxygen, Monitor, IVEvaluate, treat underlying problemsEvaluate, treat underlying problems

Patient may have CHF with pulmonary Patient may have CHF with pulmonary edema or Acute MIedema or Acute MI

WPWWPW

WPWWPW

Supraventricular Tachycardia (SVT)Supraventricular Tachycardia (SVT)

Supraventricular origin that is:Supraventricular origin that is:NotNot a sinus rhythma sinus rhythmNotNot atrial fibrillation or flutteratrial fibrillation or flutterNotNot WAP or MATWAP or MAToften segregated intooften segregated into

Nonparoxysmal Atrial Tachycardia (ectopic)Nonparoxysmal Atrial Tachycardia (ectopic)Paroxysmal Supraventricular Tachycardia (reentry)Paroxysmal Supraventricular Tachycardia (reentry)

Very often cannot distinguish between the twoVery often cannot distinguish between the two

Supraventricular TachycardiaSupraventricular Tachycardia

Nonparoxysmal Atrial TachNonparoxysmal Atrial TachEnhanced automaticityEnhanced automaticityPatient cannot pinpoint onsetPatient cannot pinpoint onsetOften caused by digitalis toxicityOften caused by digitalis toxicity






Characteristics of Nonparoxysmal Atrial TachCharacteristics of Nonparoxysmal Atrial TachHeart Rate:Heart Rate: usually 160usually 160--240240RhythmRhythm: regular: regularPacemakerPacemaker SiteSite: one ectopic atrial site: one ectopic atrial siteP WavesP Waves: present but not appearing as normal P : present but not appearing as normal P waves, similar to each other, may not be easily waves, similar to each other, may not be easily identifiableidentifiablePP--R IntervalR Interval: not applicable: not applicableRR--R IntervalR Interval: usually equal : usually equal QRS ComplexQRS Complex: usually narrow: usually narrowP to QRSP to QRS: if P waves visible, one to one relationship: if P waves visible, one to one relationship



Nonparoxysmal Atrial TachNonparoxysmal Atrial TachManagementManagement

Correct underlying cause if possibleCorrect underlying cause if possibleIf hemodynamically unstable:If hemodynamically unstable:

consider immediate cardioversionconsider immediate cardioversion

If hemodynamically If hemodynamically stablestable, consider:, consider:Diltiazem, 0.25 mg/kg slow IV over 2 min, may Diltiazem, 0.25 mg/kg slow IV over 2 min, may repeat in 15 mins at 0.35 mg/kg slow IVrepeat in 15 mins at 0.35 mg/kg slow IVMetoprolol, 5 mg slow IV over 2Metoprolol, 5 mg slow IV over 2--5 mins, may repeat 5 mins, may repeat in 5 minin 5 minAmiodarone, 150 mg IV infusion over 10 minsAmiodarone, 150 mg IV infusion over 10 mins

Supraventricular TachycardiaSupraventricular TachycardiaParoxysmal Supraventricular Tachycardia Paroxysmal Supraventricular Tachycardia (PSVT)(PSVT)

CausesCausesreentry mechanism at AV junction with or without an reentry mechanism at AV junction with or without an accessory pathwayaccessory pathwayonset may occur due toonset may occur due to

increased sympathetic toneincreased sympathetic tonestimulant usestimulant useelectrolyte abnormalitieselectrolyte abnormalitiesanxiety/emotional stressanxiety/emotional stress

Clinical significance dependent on rate and Clinical significance dependent on rate and underlying cardiac functionunderlying cardiac function

Supraventricular TachycardiaSupraventricular TachycardiaParoxysmal Supraventricular Tachycardia Paroxysmal Supraventricular Tachycardia (PSVT)(PSVT)

Episodes begin/end suddenlyEpisodes begin/end suddenlyHealthy patients c/o palpitationsHealthy patients c/o palpitationsPatients with heart disease c/oPatients with heart disease c/o

WeaknessWeaknessDizzinessDizzinessShortness of breathShortness of breathChest painChest painPulmonary edemaPulmonary edema


Characteristics of Paroxysmal SVTCharacteristics of Paroxysmal SVTHeart Rate:Heart Rate: usually 160usually 160--240240RhythmRhythm: regular: regularPacemakerPacemaker SiteSite: one ectopic atrial site: one ectopic atrial siteP WavesP Waves: usually not identifiable: usually not identifiablePP--R IntervalR Interval: not applicable: not applicableRR--R IntervalR Interval: usually equal : usually equal QRS ComplexQRS Complex: usually narrow: usually narrowP to QRSP to QRS: not applicable: not applicable

Supraventricular TachycardiaSupraventricular TachycardiaManagementManagementOxygen, Monitor, IVOxygen, Monitor, IVAssess for Stable vs UnstableAssess for Stable vs Unstable

If UnstableIf UnstableImmediately cardiovertImmediately cardiovert

Supraventricular TachycardiaSupraventricular TachycardiaAssess for Stable vs Unstable (cont)Assess for Stable vs Unstable (cont)

If StableIf StableVagal maneuversVagal maneuvers

Avoid in digitalis toxicityAvoid in digitalis toxicityMay produce AV blocks or asystoleMay produce AV blocks or asystole

AdenosineAdenosine6 mg RAPID IV push, may repeat in 16 mg RAPID IV push, may repeat in 1--2 minutes at 12 mg 2 minutes at 12 mg RAPID IV push, then 12 mg RAPID IV pushRAPID IV push, then 12 mg RAPID IV pushfollow each dose follow each dose immediatelyimmediately with a 10with a 10--20 cc flush20 cc flushBlocks conduction through AV nodeBlocks conduction through AV nodeMay produce transient aystoleMay produce transient aystoleShort halfShort half--life (<6 seconds)life (<6 seconds)Drug InteractionsDrug Interactions

Supraventricular TachycardiaSupraventricular TachycardiaAssess for Stable vs Unstable (cont)Assess for Stable vs Unstable (cont)

If Stable PSVT remains after Adenosine and vagal If Stable PSVT remains after Adenosine and vagal maneuver, may consider:maneuver, may consider:

Beta blockerBeta blockerMetoprolol, 5 mg slow IV over 2Metoprolol, 5 mg slow IV over 2--5 mins, may repeat in 5 5 mins, may repeat in 5 minminONLYONLY if NO history of heart disease or CHFif NO history of heart disease or CHF

DiltiazemDiltiazem0.25 mg/kg slow IV over 2 min, may repeat in 15 mins at 0.25 mg/kg slow IV over 2 min, may repeat in 15 mins at 0.35 mg/kg slow IV0.35 mg/kg slow IV

AmiodaroneAmiodarone150 mg IV infusion over 10 mins150 mg IV infusion over 10 mins

Synchronized CardioversionSynchronized Cardioversion

Sedate, if possibleSedate, if possibleValium 5 to 10 mg IV orValium 5 to 10 mg IV orVersed 2.5 Versed 2.5 -- 5 mg IV5 mg IVAdminister slowlyAdminister slowly

may cause hypotension and/or respiratory may cause hypotension and/or respiratory depressiondepression

Administer to produce amnestic effectAdminister to produce amnestic effectPrepare for Synchronized cardioversionPrepare for Synchronized cardioversion

Synchronized CardioversionSynchronized Cardioversion

Energy SettingsEnergy Settings50 J (PSVT/Atrial Flutter)50 J (PSVT/Atrial Flutter)100J100J200J200J300J300J360J360J

Digitalis Toxicity: CAUTION!Digitalis Toxicity: CAUTION!Cardioversion may produce VFCardioversion may produce VF

Vagal ManeuversVagal ManeuversIncrease parasympathetic toneIncrease parasympathetic toneSlow heart rateSlow heart rateSlow conduction through AV nodeSlow conduction through AV nodeManeuversManeuvers

Valsalva maneuverValsalva maneuverHave patient hold breath, bear downHave patient hold breath, bear down““Bear down as if having a bowel movementBear down as if having a bowel movement””

Vagal ManeuversVagal ManeuversCarotid sinus massageCarotid sinus massage

USE with extreme caution USE with extreme caution IFIF at all!at all!ContraindicationsContraindications

Patient >50Patient >50History of CVA or heart diseaseHistory of CVA or heart diseaseCarotid bruitCarotid bruitUnequal carotidsUnequal carotids

ProcedureProcedureBegin with right carotidBegin with right carotidMassage 15 to 20 secondsMassage 15 to 20 secondsWait 2 to 3 minutes, go to left carotidWait 2 to 3 minutes, go to left carotidOnly one carotid at a timeOnly one carotid at a time

Vagal ManeuversVagal Maneuvers

Divers ReflexDivers ReflexHold breath, immerse face in cold waterHold breath, immerse face in cold waterCan be combined with Valsalva maneuverCan be combined with Valsalva maneuverContraindicated in ischemic heart diseaseContraindicated in ischemic heart diseaseUsually performed in young childrenUsually performed in young children

Junctional RhythmsJunctional Rhythms

Premature Junctional ComplexPremature Junctional Complex

PathophysiologyPathophysiologyEarly complex originating from the AV nodeEarly complex originating from the AV nodeCausesCauses

Digitalis toxicity (most common cause)Digitalis toxicity (most common cause)Increased vagal toneIncreased vagal toneHypoxiaHypoxiaCAD usually following AMICAD usually following AMI

A premature complex, NOT an ECG rhythmA premature complex, NOT an ECG rhythm



CharacteristicsCharacteristicsHeart Rate:Heart Rate: dependent on underlying rhythmdependent on underlying rhythmRhythmRhythm: irregular due to PJC: irregular due to PJCPacemakerPacemaker SiteSite: dependent on underlying rhythm: dependent on underlying rhythmP WavesP Waves: dependent on underlying rhythm; P wave may : dependent on underlying rhythm; P wave may be inverted, buried in QRS, absent or after QRSbe inverted, buried in QRS, absent or after QRSPP--R IntervalR Interval: dependent on underlying rhythm: dependent on underlying rhythmRR--R IntervalR Interval: dependent on underlying rhythm: dependent on underlying rhythmQRS ComplexQRS Complex: usually narrow: usually narrowP to QRSP to QRS: not applicable: not applicable


PJCsPJCs

ManagementManagementGenerally No TreatmentGenerally No TreatmentAssess Underlying CauseAssess Underlying CauseQuinidine, Procainamide may be consideredQuinidine, Procainamide may be considered


Junctional Escape RhythmJunctional Escape Rhythm

CausesCausesSA Node DiseaseSA Node DiseaseIncreased Vagal ToneIncreased Vagal ToneDigitalisDigitalisInferior Wall MIInferior Wall MINormal on Temporary BasisNormal on Temporary Basis

Junctional Escape RhythmJunctional Escape RhythmCharacteristicsCharacteristics

Heart Rate:Heart Rate: usually 40usually 40--60 bpm60 bpmRhythmRhythm: ventricular rhythm is regular: ventricular rhythm is regularPacemakerPacemaker SiteSite: escape pacemaker in the AV junction: escape pacemaker in the AV junctionP WavesP Waves: may or may not be present; may precede, be : may or may not be present; may precede, be buried in or follow QRS; abnormal appearingburied in or follow QRS; abnormal appearingPP--R IntervalR Interval: usually abnormally short: usually abnormally shortRR--R IntervalR Interval: usually regular: usually regularQRS ComplexQRS Complex: usually narrow: usually narrowP to QRSP to QRS: may not be applicable: may not be applicable


Junctional Escape RhythmJunctional Escape Rhythm

ManagementManagementTreat Only if UnstableTreat Only if UnstableManage as Unstable BradycardiaManage as Unstable Bradycardia

Accelerated Junctional RhythmAccelerated Junctional Rhythm

CausesCausesEnhanced AV junction automaticityEnhanced AV junction automaticityUsually digitalis toxicityUsually digitalis toxicity

CharacteristicsCharacteristicsSame as Junctional Escape Rhythm except Same as Junctional Escape Rhythm except HR > 60 but < 100 bpmHR > 60 but < 100 bpm

ManagementManagementOxygen, monitor, IVOxygen, monitor, IVTreat the underlying causeTreat the underlying causeObserve for other arrhythmiasObserve for other arrhythmias


Junctional TachycardiaJunctional TachycardiaCausesCauses

Myocardial ischemiaMyocardial ischemiaStimulantsStimulantsDigitalis toxicityDigitalis toxicity

CharacteristicsCharacteristicsSame as Junctional Escape Rhythm exceptSame as Junctional Escape Rhythm exceptHR > 100HR > 100


Junctional TachycardiaJunctional Tachycardia

ManagementManagementConsider the possibility of Digitalis ToxicityConsider the possibility of Digitalis ToxicityStableStable

Oxygen, Monitor, IVOxygen, Monitor, IVVagal ManeuversVagal ManeuversDiltiazem or VerapamilDiltiazem or Verapamil

Junctional TachycardiaJunctional Tachycardia

ManagementManagementUnstableUnstable

Oxygen, Monitor, IVOxygen, Monitor, IVSedateSedateCardiovertCardiovert

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Atrial & Junctional Dysrhythmias - Miami County EMS · Atrial & Junctional Dysrhythmias Atrial zPremature Atrial ... Not a common dysrhythmia. ... atrial fibrillation or flutter z