Introduction to Ventricular Rhythms

Overview

This page provides an introduction to ventricular rhythms and links to training materials on this website.

When the ventricles handle the pacemaking role, they can be observed on EKG tracings. This website and related websites provide training, practice drills and quizzes related to ventricular rhythms.

There are several type of ventricular rhythms:

  • Accelerated Idioventricular Rhythm
  • Asystole
  • Idioventricular Rhythm
  • Premature Ventricular Complex
  • Premature Ventricular Complex - Bigeminy
  • Premature Ventricular Complex - Trigeminy
  • Premature Ventricular Complex - Quadrigeminy
  • Ventricular Fibrillation
  • Ventricular Tachycardia
  • Ventricular Tachycardia Monomorphic
  • Ventricular Tachycardia Polymorphic
  • Torsade de Pointes

Ventricular Rhythm Types

Accelerated Idioventricular Rhythm

Accelerated Idioventricular Rhythm EKG tracing Accelerated idioventricular rhythm occurs when three or more ventricular escape beats appear in a sequence. Heart rate will be 50-100 bpm. The QRS complex will be wide (0.12 sec. or more).

Asystole

Asystole EKG tracing Asystole is the state of no cardiac electrical activity and no cardiac output. Immediate action is required.

Idioventricular Rhythm

Idioventricular Rhythm EKG tracing Idioventricular rhythm is a slow rhythm of under 50 bpm. It indicates that then ventricles are producing escape beats.

Premature Ventricular Complex

Premature Ventricular Complex EKG tracing Premature ventricular complexes (PVCs) occur when a ventricular site generates an impulse. This happens before the next regular sinus beat. Look for a wide QRS complex, equal or greater than 0.12 sec. The QRS complex shape can be bizarre. The P wave will be absent.

Premature Ventricular Complex - Bigeminy

Premature Ventricular Complex - Bigeminy EKG tracing

Premature Ventricular Complex - Trigeminy

Premature Ventricular Complex - Trigeminy EKG tracing

Premature Vent. Complex: Quadrigeminy

Premature Ventricular Complex - Quadrigeminy EKG tracing

Ventricular Fibrillation

Ventricular Fibrillation EKG tracing Ventricular fibrillation originates in the ventricles and it chaotic. No normal EKG waves are present. No heart rate can be observed. Ventricular fibrillation is an emergency condition requiring immediate action.

Ventricular Tachycardia

Ventricular Tachycardia EKG tracing A sequence of three PVCs in a row is ventricular tachycardia. The rate will be 120-200 bpm. Ventricular Tachycardia has two variations, monomorphic and polymorphic. These variations are discussed separately.

Ventricular Tachycardia Monomorphic

Ventricular Tachycardia Monomorphic EKG tracing Monomorphic ventricular tachycardia occurs when the electrical impulse originates in one of the ventricles. The QRS complex is wide. Rate is above 100 bpm.

Ventricular Tachycardia Polymorphic

Ventricular Tachycardia Polymorphic EKG tracing Polymorphic ventricular tachycardia has QRS complexes that very in shape and size. If a polymorphic ventricular tachycardia has a long QT Interval, it could be Torsade de Pointes.

Torsade de Pointes

Torsade de Pointes EKG tracing Torsade de Pointes is a special form of ventricular tachycardia. The QRS complexes vary in shape and amplitude and appear to wind around the baseline.
Click To Begin Ventricular Rhythms Training Module

Overview

Ventricular Rhythms

Thomas E. O'Brien
AS CCT CRAT RMA

Learning Objectives

At the conclusion of this training module the reader will be able to:

  • Recall and apply the 5-steps of heart rhythm interpretation
  • Recognize the difference between regular and irregular rhythms
  • Recall the normal range for PR interval and QRS complex
  • Recognize the features and qualifying criteria for the following complexes and rhythms:
    • Premature Ventricular Complexes
    • Agonal Rhythm
    • Idioventricular Rhythm
    • Accelerated Idioventricular Rhythm
    • Ventricular Tachycardia
    • Ventricular Fibrillation
    • Asystole

Using This Presentation

how to use this presentation image

Ventricular Rhythms

Introduction Part 1

  • Rhythms are often named according to the origin of the electrical activity in the heart or the structure where the problem is occurring.
  • Ventricular Rhythms are aptly named due to the locus of stimulation being the ventricles (Purkinje network).
  • Dysrhythmias in this category occur as a result of either a failure of the higher (faster) pacemakers within the heart or an abnormal locus of stimulation within the ventricles is occurring at a faster rate than the other pacemaker sites and thus takes over as the pacemaker of the heart.
  • Remember, the fastest electricity in the heart (regardless of location) will dictate the heart rate.

Introduction Part 2

  • Each rhythm in this category will share unique morphologic features which separate them from other rhythms.
  • Other than Asystole and Ventricular Fibrillation which are unique even within this category, the remaining ventricular rhythms typically present without P waves and will display a wide, bizarre QRS complex (measuring 0.12 seconds or greater).
  • After learning the unique features just described, it is simply a matter of recalling the heart rate range associated with the dysrhythmia.

Chart of Types

Ventricular Rhythms

(no P wave, wide - bizarre QRS if present)
RhythmRate
Asystole0
Agonalless than 20 bpm
Idioventricular20-40 bpm
Accelerated Idioventricular 40-100 bpm
*Ventricular Tachycardia > 100 bpm
*Ventricular FibrillationElectrical Chaos
*Only two rhythms that are treated with defibrillation.

Terminology

Part 1

Regardless of rhythm category, morphology of waveforms and pattern of occurrence are important aspects to include in an accurate interpretation.


Unifocal – abnormal complexes are of the same shape
ventricular ecg image 101


Multifocal – abnormal complexes are of two or more different shapes. This indicates the impulse causing the PVC’s are coming from different locations.
ventricular ecg image 102


Bigeminy – abnormal complexes occur every second complex
ventricular ecg image


Trigeminy– abnormal complexes occur every third complex
ventricular ecg image 2

Part 2

Regardless of rhythm category, morphology of waveforms and pattern of occurrence are important aspects to include in an accurate interpretation.


Quadgeminy– abnormal complexes occur every fourth complex
ventricular ecg image 3


Couplet – Two PVC’s together
ventricular ecg image 4


Run of Ventricular Tachycardia
(V Tach) – Three or more PVC’s in a row at a rate of 100 bpm or greater. Also known as Triplet PVC’s or Salvo PVC’s
ventricular ecg image 5


Premature Ventricular Complexes (PVC's)

Description 1

  • PVC’s may occur for a number of different reasons i.e., diet, fatigue, stress, disease, ischemia to name a few.
  • Premature complexes frequently occur in bradycardic rhythms, but may occur almost any time.
  • PVC’s occur when an early electrical impulse occurs from a location in either ventricle.

ventricular ecg image 6

Description 2

  • This early impulse causes an early cardiac complex which disrupts the underlying rhythm.
  • The locus of stimulation being different, results in a change in the morphology of the cardiac complex.
  • Note the absence of P wave and the wide, bizarre QRS complex.
  • PVC’s can occur occasionally or frequently.
  • PVC’s can be observed with or without a pattern
ventricular ecg image 109

Practice Strip

  • Analyze this tracing using the five steps of rhythm analysis.
  • Compare your answers with the answers on the next slide.

ventricular ecg image 110

Answers

  • Rhythm: Irregular
  • Rate: 60
  • P Wave: upright and uniform, absent on early complex
  • PR interval: 0.16 sec
  • QRS: 0.08 sec, early complex wide and bizarre 0.16 sec
  • Interpretation: Sinus Rhythm with PVC
ventricular ecg image 110

Agonal Rhythm

Description

  • This is a life-threatening dysrhythmia. Agonal rhythm is often the last ordered semblance of organized electrical activity in the heart prior to death.
  • Heart rate is less than 20 bpm, without P waves and a wide, bizarre QRS complex.
  • The rate is often so slow, that on a singular six-second rhythm strip it will be impossible to determine whether the rhythm is regular or irregular. There must be at lest three complexes on the tracing to make this call. Many times there will only be one or two complexes captured on the tracing.
ventricular ecg image 111

Practice Strip

  • Analyze this tracing using the five steps of rhythm analysis.
  • Compare your answers with the answers on the next slide.

ventricular ecg image 112

Answers

  • Rhythm: Cannot determine (only two complexes)
  • Rate: 20 (using the six-second technique)
  • Rate: 14 (using the 1500 technique – 110 small boxes/1500)
  • P Wave: absent
  • PR interval: n/a
  • QRS: Wide and bizarre 0.20 sec
  • Interpretation: Idioventricular Rhythm
ventricular ecg image 112b

Idioventricular Rhythm

Description

  • The morphologic features continue with the dysrhythmia. No P wave, wide and bizarre QRS.
  • The heart rate is between 20 – 40 bpm.
ventricular ecg image 113

Practice Strip

  • Analyze this tracing using the five steps of rhythm analysis.
  • Compare your answers with the answers on the next slide.

ventricular ecg image 114b

Answers

  • Rhythm: Regular
  • Rate: 34
  • P Wave: absent
  • PR interval: n/a
  • QRS: Wide and bizarre 0.24 sec
  • Interpretation: Idioventricular Rhythm
ventricular ecg image 114

Accelerated Idioventricular Rhythm

Description

  • The morphologic features continue with the dysrhythmia. No P wave, wide and bizarre QRS.
  • The heart rate is between 40 – 100 bpm.
  • Note the abnormal shape and width of the QRS complexes.
  • Patients with this dysrhythmia may actually be hemodynamically stable when the heart rate is within the “normal” range. This rhythm must always be reported whether the patient can tolerate it or not.
ventricular ecg image 115

Practice Strip

  • Analyze this tracing using the five steps of rhythm analysis.
  • Compare your answers with the answers on the next slide.

ventricular ecg image 116

Answers

  • Rhythm: Regular
  • Rate: 41
  • P Wave: absent
  • PR interval: n/a
  • QRS: Wide and bizarre 0.16 sec
  • Interpretation: Accelerated Idioventricular Rhythm
ventricular ecg image 116

Ventricular Tachycardia

Description

  • The morphologic features continue with the dysrhythmia. No P wave, wide and bizarre QRS.
  • Ventricular Tachycardia occurs when the rate exceeds 100 bpm.
  • Approximately 50% of patients become unconscious at the onset of ventricular tachycardia.
  • Although patients in V Tach may be treated with a defibrillator, not all patients in Ventricular Tachycardia require this level of treatment.
  • Depending upon their level of consciousness and blood pressure. The patient may be treated with medications, synchronized cardioversion or in the worst case scenario a defibrillator and BLS/ACLS response.
  • This rhythm must always be reported whether the patient appears stable or not. (Follow your local reporting and treatment protocols)
ventricular tachycardia tracing

Practice Strip

  • Analyze this tracing using the five steps of rhythm analysis.
  • Compare your answers with the answers on the next slide.
ventricular tachycardia tracing #2

Answers

  • Rhythm: Regular
  • Rate: 150
  • P Wave: absent
  • PR interval: n/a
  • QRS: Wide and bizarre
  • Interpretation: Ventricular Tachycardia
ventricular tachycardia tracing #2

Ventricular Fibrillation

Description

  • The morphologic features are different with this dysrhythmia. No P wave and no QRS complexes. This rhythm presents with a chaotic waveform which reflects the electrical chaos occurring within the heart.
  • The heart is not actually beating as we know it. The chaos occurs as a result of small regions of tissue which are independently depolarizing.
  • This rapid disorganized electrical activity actually makes the heart appear to quiver in response to this activity. Some have described it as shaking like Jello.
  • Fibrillatory waves may be coarse or very fine. This is based upon their size. The longer V Fib occurs, the smaller the waveforms are likely to be.
  • (Description continues on next slide)
ventricular fibrillation tracing part 1

Description (continued)

  • Coarse V Fib is when a majority of the waveforms measure 3 mm or greater
  • Fine V Fib is when a majority of the waveforms measure less than 3 mm
  • This is absolutely a life-threatening dysrhythmia which requires, immediate, effective, and aggressive care.
  • (Follow your local reporting and treatment protocols)
  • If your patient is talking to you when you see this on the monitor, then your patient is not in V Fib. Always, check your patient first, but there will likely be a loose or disconnected lead wire or electrode.
ventricular fibrillation tracing part 2

Practice Strip

  • Analyze this tracing using the five steps of rhythm analysis.
  • Compare your answers with the answers on the next slide.
ventricular ecg image 120

Answers

  • Rhythm: Irregular
  • Rate: Unable to determine
  • P Wave: absent
  • PR interval: absent
  • QRS: absent
  • Interpretation: Ventricular Fibrillation (Fine)
ventricular ecg image 120

Asystole

Description

  • This dysrhythmia occurs when there is a total absence of electrical activity in the heart.
  • The patient is clinically dead.
  • Sometimes this tracing is referred to as straight line or flat line.
  • There will be an absence of P waves and QRS complexes.
  • True Asystole is an absolute medical emergency.
  • (Follow your local reporting and treatment protocols)
  • If your patient is speaking to you, they are NOT in Asystole. Check your attachments and equipment.
asystole tracing

Practice Strip

  • Analyze this tracing using the five steps of rhythm analysis.
  • Compare your answers with the answers on the next slide.
ventricular ecg image 121

Answers

  • Rhythm: Absent
  • Rate: 0
  • P Wave: absent
  • PR interval: n/a
  • QRS: absent
  • Interpretation: Asystole
ventricular ecg image 121

Ventricular Asystole

Description

  • Another form of Asystole you may encounter is called Ventricular Asystole.
  • The features are the same as traditional Asystole, with one exception.
  • There will be P waves present in this tracing.
  • The patient is clinically dead. The patient will not survive with just atrial depolarization.
  • (Follow your local reporting and treatment protocols)
ventricular asystole tracing

Practice Strip

  • Analyze this tracing using the five steps of rhythm analysis.
  • Compare your answers with the answers on the next slide.
ventricular ecg image 122

Answers

  • Rhythm: Regular
  • Rate: Atria – 52, Ventricles - 0
  • P Wave: Upright and uniform
  • PR interval: absent
  • QRS: absent
  • Interpretation: Ventricular Asystole
ventricular ecg image 122

Test Questions 1-4

Question #1

When analyzing a rhythm strip, it qualifies as being regular when

A. the QT intervals are the same
B. the PR interval measures the same
C. the QRS complexes measures the same
D. the R - R intervals measure the same




Question #2

Which of the following steps is not one of the five-steps of rhythm analysis?

A. PR interval measurement
B. Rhythm regularity
C. QT Interval
D. QRS complex measurement




Question #3

Which of the following is considered normal range of the QRS complex?

A. 0.12 - 0.20 minutes
B. 0.06 - 0.10 minutes
C. 0.12 - 0.20 seconds
D. 0.06 - 0.10 seconds




Question #4

Which of the following is considered normal range of the PR interval?

A. 0.12 - 0.20 minutes
B. 0.06 - 0.10 minutes
C. 0.12 - 0.20 seconds
D. 0.06 - 0.10 seconds





Test Questions 5-9

Question #5

Which feature is most closely associated with ventricular rhythms?

A. Narrow QRS complex
B. PR interval measuring greater than 0.20 seconds
C. Absence of P waves and wide & bizarre QRS complexes




Question #6

Bigeminy PVC’s are occur how often in a cardiac tracing?

A. Not at all
B. Every fourth complex
C. Every third complex
D. Every second complex




Question #7

What is the difference between Accelerated Idioventricular Rhythm and Ventricular Tachycardia?

A. Absence of P waves
B. Heart rate greater than 100 bpm
C. Inverted P waves
D. Wide and bizarre QRS complex




Question #8

What is another name for Run of Ventricular Tachycardia?

A. Triplet or Salvo PVC’s
B. Trigeminy PVC’s
C. Bigeminy PVC’s
D. Quadgeminy PVC’s




Question #9

Which rhythm presents with regularly occurring P waves and a total absence of QRS complexes?

A. Ventricular Fibrillation
B. Ventricular Tachycardia
C. Ventricular Asystole
D. Asystole





Test Questions 10-12

Question #10

ventricular quiz tracing

Select the heart rate most closely associated with this tracing.

A. 200
B. 166
C. 100
D. 87




Question #11

ventricular quiz tracing

What is the most correct interpretation of this tracing?

A. PVC’s
B. Accelerated Idioventricular Rhythm
C. Ventricular Fibrillation
D. Ventricular Tachycardia




Question #12

ventricular quiz tracing

What is the PR interval measurement in this tracing?

A. 0.12 sec
B. 0.42 sec
C. No PR interval to measure
D. 0.68 sec





Test Questions 13-15

Question #13

What would be the most proper description of the atrial morphology in this tracing?

ekg ventricular quiz tracing 12
A. Upright and uniform
B. Absent
C. Variable
D. Biphasic




Question #14

What is the most correct interpretation of this tracing?

ekg ventricular quiz tracing 12
A. Sinus Bradycardia
B. Agonal Rhythm
C. Idioventricular Rhythm
D. Asystole




Question #15

Which term is most appropriately used to describe the QRS morphology in this tracing?

ekg ventricular quiz tracing 12
A. Normal
B. Wide and bizarre
C. Variable
D. All answers are incorrect





Test Questions 16-18

Question #16

What would be the most proper description of the pattern of the activity in this tracing?

ekg ventricular quiz tracing 15
A. Regularly Irregular
B. Constant
C. Absent
D. Irregular




Question #17

Select the number that most closely represents the heart rate.

ekg ventricular quiz tracing 15
A. 80
B. 65
C. 45
D. 30




Question #18

Select the term that most closely describes the abnormality in this tracing.

ekg ventricular quiz tracing 15
A. Bigeminy PVC’s
B. Trigeminy PVC’s
C. Run of Atrial Tachycardia
D. Run of Ventricular Tachycardia





Test Questions 19-21

Question #19

What is the most correct interpretation of this tracing?

ekg junctional quiz tracing 19
A. Sinus Bradycardia with PJC’s
B. Sinus Bradycardia with multifocal PVC’s
C. Sinus Bradycardia
D. Sinus Bradycardia with PAC’s




Question #20

What is the most correct interpretation of the abnormality in this tracing?

ekg junctional quiz tracing 19
A. Bigeminy PVC’s
B. Run of Ventricular Tachycardia
C. Trigeminy PVC’s
D. Couplet PVC’s




Question #21

What would be a proper term to describe the P wave on the cardiac complex in this image?

ekg junctional quiz tracing 19
A. Absent
B. Inverted
C. Biphasic
D. Wide and bizarre





Test Questions 22-25

Question #22

Which tracing is a Couplet PVC?

A.
ekg quiz tracing 22
B.
ekg quiz tracing 22
C.
ekg quiz tracing 22
D.
ekg quiz tracing 22
A.
B.
C.
D.




Question #23

Which tracing is a Quadgeminy PVC?

A.
ekg quiz tracing 22
B.
ekg quiz tracing 22
C.
ekg quiz tracing 22
D.
ekg quiz tracing 22
A.
B.
C.
D.




Question #24

Which tracing is a Triplet PVC?

A.
ekg quiz tracing 22
B.
ekg quiz tracing 22
C.
ekg quiz tracing 22
D.
ekg quiz tracing 22
A.
B.
C.
D.




Question #25

Which tracing is a Trigeminy PVC?

A.
ekg quiz tracing 22
B.
ekg quiz tracing 22
C.
ekg quiz tracing 22
D.
ekg quiz tracing 22
A.
B.
C.
D.





EKG Self Test

EKG Rhythms Self Test

If you would like to tests the knowledge and skills learned in this module, use our EKG Rhythms Self Test. You can choose to focus this self-test on any of all of the following:

  • Sinus Mechanisms
  • Atrial Rhythms
  • Junctional Rhythms
  • Ventricular Rhythms
  • Atrioventricular Blocks
  • Pacemaker Rhythms

EKG Rhythm Tests »

Training Resources

Ventricular Rhythms Training Module

A good starting point is our ventricular rhythms module, which focuses on the morphologic features and qualifying criteria of ventricular rhythms. The module includes interactive Q&A.

Ventricular Rhythms

EKG Rhythm Tests

Hundreds heart rhythms in this practice test. Test can be tailored for specific learning needs.

EKG Rhythm Tests


External References

Wikipedia
Free Dictionary