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Accelerated junctional rhythm on an ECG strip

A regular narrow-complex rhythm at 60-100/min with no upright P waves: the junction firing faster than an escape would.

What to look for

A junctional rhythm at 60-100/min. That's faster than a junctional escape (40-60) and slower than junctional tachycardia (over 100). The QRS complexes are narrow and regular, with no upright sinus P waves. When you do see a retrograde P, it's inverted in II just before (PR under 0.12 s), inside or just after the QRS. The rate sits in the normal range, so it's easy to call it sinus rhythm until you look at the P waves.

Examples

Each strip is 6 seconds of lead II, drawn to scale (25 mm a second, 10 mm a millivolt), so you can count boxes the way you would on paper. Each one is a different example, measured below it.

Example 1 · lead II · 6 seconds
II25 mm/s · 10 mm/mV
Rate
93/min10 QRS complexes in 6 seconds × 10 = 100/min
Rhythm
Regular
P waves
Inverted in II, just before each QRS
P to QRS
Each inverted P comes just before its QRS, too close to have conducted it (PR under 0.12 s)
PR
None to measure
QRS
0.11 s, narrow
Example 2 · lead II · 6 seconds
II25 mm/s · 10 mm/mV
Rate
88/min9 QRS complexes in 6 seconds × 10 = 90/min
Rhythm
Regular
P waves
Not visible (hidden in the QRS)
P to QRS
No visible P waves (the retrograde P is hidden in the QRS)
PR
None to measure
QRS
0.09 s, narrow
Example 3 · lead II · 6 seconds
II25 mm/s · 10 mm/mV
Rate
83/min8 QRS complexes in 6 seconds × 10 = 80/min
Rhythm
Regular
P waves
Inverted in II, just after each QRS
P to QRS
Each inverted P comes just after its QRS
PR
None to measure
QRS
0.11 s, narrow

Don't confuse it with

Want a new strip every time? The ECG Drill in the app draws a fresh, measured example on every try and steers you toward the rhythms you miss. It's part of the Paramedic level, and you can try 5 strips a day free.

Try the ECG Drill

Where the criteria come from

Others in the Junctional group