Chapter 7

JUNCTIONAL DYSRHYTHMIAS

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 Learning Outcomes
7.1 Describe the various junctional dysrhythmias.

7.2 Analyze premature junctional complexes and their effect on

the patient, including basic patient care and treatment.

7.3 Analyze junctional escape rhythm and its effect on the

patient, including basic patient care and treatment.

7.4 Analyze accelerated junctional rhythm and its effect on the

patient, including basic patient care and treatment.

7.5 Analyze junctional tachycardia rhythm and its effect on the

patient, including basic patient care and treatment.

7.6 Analyze supraventricular tachycardia rhythm and its effect

on the patient, including basic patient care and treatment.
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 Learning Outcome 7.1
Introduction to Junctional Dysrhythmias
Key Terms
AV junction

Retrograde

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 Introduction to Junctional Dysrhythmias
AV junction can function as a backup pacemaker.

Junctional rhythms
• Result of electrical impulses coming from the AV node rather
than SA node
• Inverted P wave
• P wave may occur before, during (hidden in), or after the QRS
complex.

Inherent rate of AV junction is 40 to 60 beats per minute.

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 Learning Outcome 7.1
Apply Your Knowledge #1

What causes the inverted P wave found with junctional

rhythms?

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 Learning Outcome 7.1
Apply Your Knowledge #1
Answer
What causes the inverted P wave found with junctional
rhythms?

Electrical impulses are coming from the AV junction,

causing depolarization of the atria to flow retrograde, which
causes the inverted P wave.

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 Learning Outcome 7.1
Apply Your Knowledge #2

What is the inherent rate of the AV node?

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 Learning Outcome 7.1
Apply Your Knowledge #2
Answer
What is the inherent rate of the AV node?

40 to 60 beats per minute

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 Learning Outcome 7.2
Premature Junctional Complex
Key Term
Hypotension

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 Premature Junctional Complex (PJC)
• An early electrical impulse that originates from the AV
junction

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 Premature Junctional Complex: Criteria 1
Rhythm: Occasionally or frequently irregular, depending on:
• Underlying rhythm
• Number of PJCs

Rate: Depends on the underlying rhythm

P wave morphology: Inverted, and may proceed, follow, or be

buried in the QRS complex

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 Premature Junctional Complexes: Criteria 2

PR interval: Depends on location of P wave

• Shorter than normal if P wave precedes QRS.
• Absent if P wave is buried in QRS.
• Not measurable if P wave is after QRS.

QRS duration and morphology: 0.06‒0.10 second, within normal

limits

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 Premature Junctional Complex:
What You Should Know
• Isolated PJCs cause no signs or symptoms in healthy patients.
• Patients may experience hypotension (low blood pressure)
and low cardiac output if PJCs occur more than four to six
times per minute.

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 Learning Outcome 7.2
Apply Your Knowledge

What are the distinguishing characteristics of premature

junctional complexes?

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 Learning Outcome 7.2
Apply Your Knowledge
Answer
What are the distinguishing characteristics of premature
junctional complexes?

PJCs cause the rhythm to be irregular, and the inverted P

wave may occur before, during, or after the QRS complex.

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 Learning Outcome 7.3
Junctional Escape Rhythm
Key Term
Junctional escape rhythm

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 Learning Outcome 7.3
Junctional Escape Rhythm
• Originates at AV junction.
• Produces retrograde depolarization of atrial tissue.
• Stimulates depolarization of ventricles.

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 Junctional Escape Rhythm: Criteria 1
Rhythm
• P-P and R-R intervals are regular and have similar intervals.
• P-P interval may be difficult to determine due to location of P
wave.

Rate
• Ventricular: 40 to 60 bpm
• Atrial: 40 to 60 bpm, but may be unmeasurable

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 Junctional Escape Rhythm: Criteria 2

P wave morphology
• Usually inverted
• May follow, precede, or be hidden within QRS complex

PR interval:
• Before the QRS: less than 0.12 second and constant
• During or after QRS: cannot be determined

QRS duration and morphology: 0.06‒0.10 second

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 Junctional Escape Rhythm:
What You Should Know
Slower heart rate can lead to low cardiac output.
• Hypotension
• Confusion or disorientation

Report junctional escape rhythm to a licensed practitioner for

treatment.

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 Learning Outcome 7.3
Apply Your Knowledge

What are the distinguishing characteristics of junctional escape

rhythm?

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 Learning Outcome 7.3
Apply Your Knowledge
Answer
What are the distinguishing characteristics of junctional escape
rhythm?

Heart rate between 40 and 60 bpm, inverted P wave that

occurs before, during, or after the QRS complex.

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 Learning Outcome 7.4
Accelerated Junctional Rhythm
• Originates at AV junction.
• Produces retrograde depolarization of atrial tissue.
• Stimulates the depolarization of ventricles.

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 Accelerated Junctional Rhythm: Criteria 1
Rhythm
• P-P and R-R intervals are regular and similar
• P-P interval may be difficult to measure due to the location of
the P wave

Rate
• 60 to 100 beats per minute

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 Accelerated Junctional Rhythm: Criteria 2
P wave morphology
• Usually inverted
• May precede, follow, or fall within QRS complex

PR interval
• Before the QRS: less than 0.12 second and constant
• During or after QRS: cannot be determined

QRS duration and morphology: 0.06-0.10 second, within normal

limits

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 Accelerated Junctional Rhythm:
What You Should Know
• Unlikely that patient will show signs of low cardiac output.

• Observe patient for symptoms.

• Report accelerated junctional rhythm to a licensed

practitioner for treatment.

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 Learning Outcome 7.4
Apply Your Knowledge

What are the distinguishing characteristics of accelerated

junctional rhythm?

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 Learning Outcome 7.4
Apply Your Knowledge
Answer
What are the distinguishing characteristics of accelerated
junctional rhythm?

Heart rate between 60 and 100 bpm, inverted P wave that

occurs before, during, or after the QRS complex; P wave
may be absent.

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 Learning Outcome 7.5
Junctional Tachycardia
• Similar to junctional escape rhythm and accelerated
junctional rhythm
• Heart rate is faster.

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 Junctional Tachycardia: Criteria 1
Rhythm
• P-P and R-R intervals are regular and similar.
• P-P may be difficult to measure due to location and increased
heart rate.

Rate
• Ventricular: 100 to 180 bpm
• Atrial: 100 to 180 bpm, but may not be measurable if P waves
are not identifiable

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 Junctional Tachycardia: Criteria 2
P wave morphology
• Usually inverted
• May precede, follow, or fall within QRS
• May not be visible on rhythm strip
• May need to increase paper speed on cardiac monitor

PR interval
• Before the QRS: less than 0.12 second and constant
• During or after QRS: cannot be determined

QRS duration and morphology: 0.06‒0.10 second, within normal

limits

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 Junctional Tachycardia :
What You Should Know
• Patient may complain of palpitations or heart fluttering with
faster rates.
• Considered very serious or life threatening after a recent MI
• Report junctional tachycardia rhythm to a licensed
practitioner for treatment.

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 Learning Outcome 7.5
Apply Your Knowledge

What are the distinguishing characteristics of junctional

tachycardia?

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 Learning Outcome 7.5
Apply Your Knowledge
Answer
What are the distinguishing characteristics of junctional
tachycardia?

Heart rate between 100 and 180 bpm, inverted P wave that
occurs before, during, or after the QRS complex; P wave
may be absent.

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 Learning Outcome 7.6
Supraventricular Tachycardia (SVT)
Key Terms
Supraventricular

Wolfe-Parkinson-White syndrome

Delta wave

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 Supraventricular Tachycardia (SVT)
Category of rapid rhythms
• Originate in atria or AV junction
• Faster than 100 bpm

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 Supraventricular Tachycardia: Criteria 1
Rhythm
• R-R usually regular
• If identifiable, P waves usually regular

Rate
• Ventricular: 150-250 beats per minute
• Atrial: Difficult to determine unless P waves are identifiable

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 Supraventricular Tachycardia: Criteria 2
P wave morphology
• Usually not identifiable at this heart rate, since P wave may lie
inside T wave.
• May occur before, during, or after QRS complex.

PR interval: Usually unable to determine

QRS duration and morphology

• Within normal limits if duration is 0.06‒0.10 seconds
• Some rhythms result in narrow or wide QRS complexes.

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 Supraventricular Tachycardia:
What You Should Know
• Patient may be in stable or unstable condition.
• Observe patient for low cardiac output.
• Notify licensed practitioner.
• Treatment should begin as early as possible.

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 Law and Ethics
• Your role and scope of practice depend on your training and
place of employment.
• Working outside your scope of practice is illegal.

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 Learning Outcome 7.6
Apply Your Knowledge

Where in the heart does a supraventricular tachycardia

originate?

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 Learning Outcome 7.6
Apply Your Knowledge
Answer
Where in the heart does a supraventricular tachycardia
originate?

Either in the atria or in the AV junction

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 Chapter Summary 1
• The AV node and its surrounding area, including the bundle of
His, are collectively known as the AV junction.
• The inherent rate of the AV junction is 40 to 60 bpm.
• The P wave is usually inverted and can occur before, during, or
after the QRS complex, depending on where in the AV
junction the impulse originates.
• A premature junctional complex (PJC) is a single early
electrical impulse that originates in the AV junction.
• A junctional escape rhythm is one that originates at the AV
junction, produces retrograde depolarization, and stimulates
ventricular depolarization at a rate of
40 to 60 bpm.

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 Chapter Summary 2
• Accelerated junctional rhythm is similar to junctional escape
rhythm, but has a heart rate of 60 to 100 bpm.
• Junctional tachycardia is similar to junctional escape and
accelerated junctional rhythms, but has a heart rate of 100 to
180 bpm.
• Supraventricular tachycardia is a category of dysrhythmias
that originate above the ventricles and have a heart rate
above 100 bpm.
• Some SVTs are reentry dysrhythmias, and others are
reciprocating dysrhythmias.

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