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Accelerated junctional rhythm

A junctional rhythm running 60-100. The impulse spreads backward into the atria, so the P wave is inverted and sits just in front of the narrow QRS with a short PR (or hides in or after it).

A 6-second EKG rhythm strip showing Accelerated junctional rhythm.
Accelerated junctional rhythm, 6 seconds of strip. Each small box is 0.04 seconds and each large box is 0.20 seconds.

How to identify Accelerated junctional rhythm

Rate
60-100
Rhythm
Regular
P waves
Inverted, just before the QRS (or hidden in or after it)
PR interval
Short
QRS
Under 0.12 s
Clincher
Inverted P with a short PR at a normal rate: the impulse spreads backward into the atria.

Rhythms it gets mistaken for

Treatment by certification level

Open your level. Treat the patient, not the strip.

Paramedic

No rhythm treatment needed.

  • Treat the patient in front of you, not the strip.
AEMT

Pulse present and stable.

  • Oxygen only if hypoxic or short of breath, IV access, monitoring.
  • Acquire and transmit a 12-lead ECG. Interpreting it is a Paramedic skill.
  • Transport and reassess. Request a paramedic if the patient worsens.
EMT

Pulse present: assess and support.

  • Treat the patient, not the rhythm name: airway, breathing, circulation, vital signs.
  • Oxygen if the SpO2 is under 94%, the patient is short of breath, or shows signs of shock.
  • Request ALS and transport promptly. Reassess on the way.

An AED goes only on a patient who is unresponsive, not breathing and pulseless. It cannot feel a pulse, so on a patient with a pulse it can advise a shock that would do harm.

Could you pick out Accelerated junctional rhythm on a fresh strip? See how many rhythms you can identify in one minute.

Try the 60-second rhythm challenge