03.04 Atrial Flutter

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Overview of Atrial Flutter

  1. Atrial flutter
    1. Irritable  cells produce  additional electrical impulse in atria
      1. Causes atria to flutter at a fast rate
        1. 250-300 bpm
      2. AV node blocks most of the  electrical impulses from reaching the ventricles
        1. Atria contract faster than ventricles

Nursing Points for Atrial Flutter


  1. Characteristics of Atrial flutter
    1. Rhythm
      1. Irregular
      2. Regular at times
    2. Rate
      1. Atrial rate
        1. 250-300 bpm
        2. Sawtooth
      2. Ventricular rate
        1. 60-100 bpm
        2. >100 bpm
    3. P:QRS ratio
      1. Variable
        1. 4:1 or 5:1
    4. PR interval
      1. Not measurable
    5. QRS complex
      1. 0.06-0.12 seconds
        1. Varies depending on ventricular rate
  2. Nursing Interventions
    1. Acute or chronic
    2. Assess for s/s of stroke
      1. Blood pooling in atria
        1. Increased risk for clots


  1. Patient Presentation
    1. Palpitations
    2. Chest pain
    3. Lightheaded/Syncope
  2. Acute or Chronic
  3. Atrial and ventricular rates
  4. Decreased Cardiac Output
    1. Syncope
    2. Hypotension
  5. PT/INR
    1. If taking Coumadin

Therapeutic Management for Atrial Flutter

  1. Medications
    1. Antiarrhythmics
    2. Beta Blockers
    3. Calcium Channel Blockers
    4. Anticoagulants
  2. Cardioversion
    1. Synchronized
  3. Ablations

Nursing Concepts

  1. EKG Rhythms
  2. Perfusion
  3. Clotting

Patient Education

  1. Do not miss a dose of on anticoagulants
    1. Check PT/INR
  2. Check radial pulse
    1. Report if >100


Hey guys, in this lesson we are going to talk about the characteristics of atrial flutter and learn how to identify it on an EKG we are also going to talk about some of the complications, nursing interventions and treatments for a-flutter.

So if you remember the normal electrical conduction starts with the SA node, it sends an impulse to the left and the right atrium and the atria contract. Then it goes down the AV node and bundle of his, right and left bundle branches and purkinje fibers so the ventricles contract. Now in atrial flutter, there are irritable cells in the atria the produce an abnormal electrical impulse causing the atria to contract at a rate of 250-300 beats per minute. The AV node does not allow these signals to get down to the ventricles because if it did it would also contract at a faster rate. At times some of the signals get through and the ventricles contract at a rate of greater than 100 beats per minute and that is called a-flutter with rapid ventricular response. Because the atria are contracting so fast there is less time to fill up with blood. Less blood goes in the atria and the ventricles so less blood goes to the body so we have a decreased cardiac output. Now let’s look at the next strip and identify the characteristics of Atrial flutter and break it down on an EKG.

So let’s use the 6-step method to identify the rhythm, in step one we need to look at the rhythm, is it regular or irregular. So we count the boxes between R waves, from here to here and get 34 and about 38 here and about 34 here, so our rhythm is regular and irregular. Patients with atrial flutter can have a regular rhythm or irregular rhythm. Now let’s count the heart rate, because we have more P waves than QRS we have to count both. So let’s count the P waves 26 P waves, we have 26 so let’s multiply by 10 since we have a 6 second strip so we get 260 beats per minute. So now let’s count the R waves, we have 4 R waves, so multiply 4 by 10 and we have a rate of 40. So the atrial rate is 260 beats per minute and ventricular rate is 40 beats per minute. Now let’s do step 3 and look at the P:QRS ratio, do we have one P wave followed by one QRS and we do not, we definitely wave more P waves than QRS. Here we have 7 to 1 and here we have 6 to 1. So our P to QRS ratio varies and we do not have a 1:1 ratio. In step 4 we need to look at the PR interval, since we have more P waves than QRS we consider this not measurable. In step 5 we look at the QRS complex, so from here to here we have 2 boxes so 0.08 seconds and it is normal. Step 6 is to identify the rhythm and we have atrial flutter. Let’s look at the next slide because I want to show you more characteristics regarding a-flutter.

If you look at this strip, it’s the same patient and the same rhythm being monitored on 2 different leads. On this lead you can see the P waves that have a sawtooth appearance, when you see a sawtooth appearance on an EKG always associate that with atrial flutter. The top lead does not have the same looking P waves, almost looks like A-fib, always get a 12 lead EKG to confirm the rhythm. So let’s recap the characteristics of atrial flutter. The rhythm is regular or irregular, the atrial heart rate is going to be between 250-300 beats per minute P waves have a sawtooth appearance, the ventricular rate is normal, high or low depending on the patient. The P to QRS ratio will vary and will definitely not be 1 to 1. The PR interval is not measurable and the QRS complex is normal. Now let’s talk about what to do with patients that have a-flutter.

So most patients that have aflutter will present with palpitations, chest pain and lightheadedness. The most important nursing interventions are to determine if the aflutter is chronic or acute,
If people have chronic a-flutter we continue to monitor them as long as their rate is controlled and not in RVR. Make sure they are taking some type of anticoagulant, when the atria are contracting so fast they do not have enough time to fill up with blood and when they contract they don’t get rid of the blood that is sitting in the atria. The blood pools in the atria and clots up because it’s not moving if that breaks loose it goes to the brain it causes a stroke. We must monitor for s/s of stroke and patients are taking anticoagulants. People with a-flutter are at high risk for strokes, not as high as a-fib because the atria still contract with a flutter.

So the therapeutic management for atrial flutter is to assess the patient and find out if chronic or acute. If its acute and they are symptomatic we need to convert them as soon as possible. If its chronic or acute they take the same medications like antiarrhythmics, beta blockers, calcium channel blockers and anticoagulants. If they are acute and they are symptomatic they will have an amiodarone or Cardizem drip to control their rate. If that does not work they get a synchronized cardioversion, the defibrillator synchronizes with the R waves to deliver the shock after repolarization to prevent v-fib. If that does not work, they will have an ablation, an ablation is where a catheter is inserted into the femoral veins and advanced to the heart, the cells that are causing the extra electrical activity are detected and burned. This creates a scar tissue to prevent abnormal electrical activity so only the SA node initiates the impulse and they are back in a normal sinus rhythm. Unfortunately, sometimes another part of the atria may decide to act up and the a-flutter returns. But people can live with a-flutter as long as their rate is controlled and they take their medications.

So the key points and your biggest takeaways from a-flutter are to remember the abnormalities. There are more P waves than QRS and the rhythm can be regular or irregular, the P waves have a sawtooth appearance. Assess the patient and find out if its chronic or acute assess for signs and symptoms of stroke and prevent stroke. Make sure you know the treatment for aflutter which includes medications, cardioversions and ablations.

I hope this lesson has helped you understand the characteristics of atrial flutter and nursing interventions and managements. Make sure you check out all of the resources attached to this lesson and keep looking and practicing different EKGs, so you become more familiar. Now, go out and be your best self today! And, as always, happy nursing!