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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.
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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

  • Accelerated junctional rhythm vs Junctional escape rhythm

    Accelerated junctional rhythm has a rate of 60-100/min. With a junctional escape rhythm you would see a rate of 40-60/min. How to spot a junctional escape rhythm: A narrow QRS with no upright P in front of it, at the junction's own 40-60.

  • Accelerated junctional rhythm vs Junctional tachycardia

    Accelerated junctional rhythm has a rate of 60-100/min. With junctional tachycardia you would see a rate over 100/min. How to spot junctional tachycardia: Narrow and regular over 100 with an inverted or missing P. Over 100 separates it from accelerated junctional (60-100). A visible inverted P separates it from SVT, where the P is buried; with no P at all the two can look the same and are treated the same way at first.

  • Accelerated junctional rhythm vs Normal sinus rhythm

    Accelerated junctional rhythm has an inverted P wave just before or just after each QRS. With normal sinus rhythm you would see one upright P wave before every QRS, all the same shape. It starts in the AV junction: a junctional rhythm. How to spot normal sinus rhythm: Every step of the six-step read is normal.

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