The second and 7th QRS complexes are missing P-waves, and are PJCs.

Think of them as fraternal twins – they don’t look the same but they came from the same mother at the same time.

Drugs causing AV block should be reviewed and discontinued if indicated.
In the ventricles, these cells are located in the conducting tissue of the bundle of His and the Purkinje fibers. All throughout the bundle of His and the Purkinje fibers are cells (or collections of cells) that have the capability of spontaneous depolarization. The AV node doesn’t contain pacemaker cells. The QRS duration is normal. Junctional rhythm can be diagnosed by looking at an ECG: it usually presents without a P wave or with an inverted P wave. Learn how your comment data is processed.

T wave is inverted in aVL. P waves may be absent, or retrograde P waves (inverted in leads II, III, and aVF) either precede the QRS with a PR of less than 0.12 seconds or follow the QRS complex. Pacemaker cells nearest the bundle of His in the AV junction are responsible for secondary pacing function. Those who submit comments have to give their email ids, which are not displayed or distributed to any third party. Junctional beats generally originate from the bundle of His or very near to it.



But some cells outside the SA node are capable of spontaneously depolarizing and thus initiate their own impulse that can spread through the heart (just like the sinus node). Very simple: we guessed! Let’s start…. The QRS complex will be wide if the site of pathology is located in the bundle branches. There is no rule regarding the duration of the P´R interval of a junctional beat, but in my experience, it has always been less than 0.12 seconds and usually 0.08 seconds or less. The actual firing of the junctional ectopic pacemaker is not visible on the ECG for the same reason the firing of the SA node is not visible. Remember that most myocytes depend on an arriving impulse to depolarize them and stimulate them to fire and then pass along the depolarization wave. At Medicus of Houston, you are always a participant…  never just an audience!

Eventually you learned that the P waves could appear in front of the QRS. If you would like to learn more about interpreting ECGs at an advanced level, come join us in one of our presentations of the Advanced ECG Interpretation Boot Camp.

Sinus bradycardia with first-degree AV block. Later, you learned that they could have P waves but they followed the QRS. Figure 8-4. And the key characteristic of a junctional rhythm is that the P wave is messed up.

qR pattern in I and aVL also go with left anterior hemiblock.


Figure 8-18. ▪ P waves will occur in one of three patterns: ▪ PR interval will be short (0.10 second or less). Though there are some baseline artefacts, no definite P waves or fibrillary waves are seen. By the time we reach the bundle of His, there is very little autonomic neural influence and so the junctional accessory pacemakers are usually the next to intervene. Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), Ventricular Arrhythmias and Bundle-Branch Block, Advances in Catheter Ablation of Primary Ventricular Fibrillation, ECG Workout: Exercises in Arrhythmia Interpretation. Figure 8-6. This is defined as either an accelerated junctional rhythm or junctional tachycardia, depending on the rate. ▪ If the electrical impulse from the AV junction depolarizes the ventricles first and then depolarizes the atria, the P wave will be after the QRS complex. Treatment is directed at reversing the consequences of reduced cardiac output, if present, as well as identifying and correcting the underlying cause of the rhythm. Premature Junctional Complex Premature junctional complex (PJC) occurs when an irritable site within the AV node fires an impulse before the SA node. Accelerated junctional rhythm: Identifying ECG features.


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