The presence of multiple P wave morphologies indicates multiple ectopic pacemakers within the atria and/or AV junction. If ≥ 3 different P wave morphologies are seen, then multifocal atrial rhythm is diagnosed:

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If ≥ 3 different P wave morphologies are seen and the rate is ≥ 100, then multifocal atrial tachycardia (MAT) is diagnosed:

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Atrial abnormalities are most easily seen in the inferior leads (II, III and aVF) and lead V1, as the P waves are most prominent in these leads.

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We therefore interpret this tracing as showing “AV dissociation” – since at least some P waves are unrelated to the QRS complexes that follow them. The term AV dissociation should never be used as a “diagnosis” per se. Instead – it is the result of the underlying rhythm on the tracing. In this case – the underlying rhythm is sinus bradycardia at a rate of 50/minute (the P-P interval is precisely 6 large boxes in duration for each of the P waves on this tracing). AV dissociation occurs by…

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The treatment for unstable third-degree AV block in ACLS is transcutaneous pacing.

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[What are those funny looking beats????]{Frank G. Yanowitz, M.D.}The differential diagnosis of funny-looking-beats, or FLB's, primarily considers beats of supraventricular origin with aberrant conduction and ventricular ectopic beats. In this example the two FLB's have an easily seen ectopic P wave before them; therefore these are PAC's with RBBB aberration.

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