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When dealing with a NARROW complex (QRS < 120ms) tachycardia with an IRREGULAR rhythm, there are three main categories of possible rhythms to consider:
The most common sustained arrhythmia
Commonly misdiagnosed (by the ECG machine & providers)
Should have an irregularly irregular rhythm with no distinct regular atrial activity
Lead II (rhythm strip) is not 100% reliable for P-waves, look at all 12 leads and make sure to scrutinize V1 (closest to the sinus node) for P-waves
If the rhythm is regularly irregular and you have grouped or "clumped" beats, consider PAC's and second degree AV blocks (Mobitz I and II) which can mimic atrial fibrillation
Regular atrial activity (F-waves) at a rate of ~240-360 bpm
Ventricular rate is determined by the AV node, when variable, there is a regularly irregular rhythm
Sawtooth pattern is best seen in V1 & lead II
3 distinct atrial foci
Irregularly irregular rhythm
Associated with chronic pulmonary disease
As with sinus tachycardia, do not cardiovert, treat the underlying cause
To differentiate between the 3 different causes of narrow complex & irregular tachycardia…always look at what the atrium is doing (V1 typically best lead to look for atrial activity)
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