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Agonal rhythm on an ECG strip

Very slow (under 20/min), irregular, wide and misshapen complexes with no P waves: the last electrical activity of a dying heart.

What to look for

The ventricles' last, failing electrical activity. The complexes are wide and slurred, under 20/min, each a different shape and size, at irregular intervals, with no P waves. It isn't a perfusing rhythm. A patient in it almost always has no pulse, and you treat it as pulseless electrical activity (high-quality CPR and epinephrine, no shock). It decays into asystole.

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
17/min2 QRS complexes in 6 seconds × 10 = 20/min
Rhythm
Irregular
P waves
None
P to QRS
No P waves
PR
None to measure
QRS
0.22 s, wide
Example 2 · lead II · 6 seconds
II25 mm/s · 10 mm/mV
Rate
17/min2 QRS complexes in 6 seconds × 10 = 20/min
Rhythm
Irregular
P waves
None
P to QRS
No P waves
PR
None to measure
QRS
0.18 s, wide
Example 3 · lead II · 6 seconds
II25 mm/s · 10 mm/mV
Rate
18/min2 QRS complexes in 6 seconds × 10 = 20/min
Rhythm
Irregular
P waves
None
P to QRS
No P waves
PR
None to measure
QRS
0.21 s, wide

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 Ventricular group