Palpitations and Tachyarrhythmia SymptomsAPPROACH

CHEST AND CARDIOVASCULAR · 19 SECTIONS

⚲

491 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Pacemaker And Icd Related Presentations Acute Limb Ischemia And Leg Pain Suspected Deep Vein Thrombosis Symptoms Hypertension Chest Pain Palpitations And Tachyarrhythmia Symptoms Bradycardia Symptoms Syncope And Presyncope Syncope With Neurologic Concern Unilateral Leg Swelling Bilateral Leg Swelling Calf Pain And Swelling

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx69

Presenting pattern

›Pattern overview

›Palpitations description

›Tachycardia sensation

›Irregular heartbeat sensation

›Skipped beats sensation

›Fluttering sensation

OPQRST

›O onset

›Sudden onset

›Gradual onset

›First episode

›Recurrent episodes

›P provocation and palliation

›Exertion related

›Rest related

›Position related

›Valsalva related

›Caffeine related

›Alcohol related

›Stimulant related

›Stress related

›Q quality

›Regular rapid

›Irregular rapid

›Thumping

›Pounding

›Pauses

›R region and radiation

›Chest awareness

›Neck pulsations

›Throat pounding

›S severity

›Functional limitation

›Activity interruption

›Associated presyncope

›T timing

›Episode duration

›Frequency

›Time of day pattern

›Abrupt termination

›Trigger reproducibility

Associated symptoms

›Associated symptoms cluster

›Chest pain

›Dyspnea

›Syncope

›Presyncope

›Dizziness

›Diaphoresis

›Nausea

›Neurologic deficit symptoms

›Fever

Prior episodes and baseline

›Baseline comparison

›Prior similar episodes

›Prior ECG findings known

›Prior arrhythmia diagnosis

›Prior ablation

›Prior cardioversion

Context and triggers

›Contextual factors

›Recent illness

›Dehydration

›Sleep deprivation

›Pain

›Anxiety or panic symptoms

›Pregnancy or postpartum status

›Recent surgery

›Recent immobilization

Rhythm capture history

›Prior rhythm documentation

›Prior Holter or patch monitor results

›Prior wearable device tracings

›Event monitor correlation with symptoms

02Alarm Features/alarm28

Immediate life threats

›High risk presentations

›Syncope during palpitations

›Chest pain with palpitations

›Dyspnea with hypoxia

›Altered mental status

›Shock physiology

›Sustained wide complex tachycardia

Vital sign danger thresholds

›High risk vitals

›Systolic blood pressure less than 90 mmHg

›Heart rate greater than 150 per minute with symptoms

›Oxygen saturation less than 90 percent on room air

›Respiratory rate greater than 30 per minute

High risk history triggers

›High risk history

›Known structural heart disease

›Known ventricular arrhythmia history

›Inherited arrhythmia syndrome history

›Family history sudden unexplained death

›Recent stimulant or cocaine exposure

High risk ECG features

›ECG red flags

›Preexcitation pattern

›QTc prolongation

›Brugada pattern

›Ischemic changes

›High grade AV block

Escalation triggers

›Escalation criteria

›If unstable, synchronized cardioversion

›If pulseless, cardiac arrest algorithm

›If ongoing ischemia, emergent cardiology activation

03Medications/meds23

Medication reconciliation

›Current medications

›Beta blockers

›Calcium channel blockers

›Antiarrhythmics

›Anticoagulants

›Thyroid hormone

›Diuretics

Arrhythmogenic medications

›Medication risk exposures

›QT prolonging agents

›Sympathomimetics

›ADHD stimulants

›Decongestants

›Bronchodilators

Recent changes and adherence

›Medication course

›Recent dose changes

›Missed doses

›Recent discontinuation

›Recent initiation

Drug interactions and contraindications

›Interaction hazards

›AV nodal blocker stacking

›QT prolongation combinations

›CYP interactions with antiarrhythmics

›Anticoagulant interactions

04Diet/diet14

Stimulants and hydration

›Dietary contributors

›Caffeine intake pattern

›Energy drinks

›Pre workout supplements

›Hydration deficit

Alcohol and withdrawal

›Alcohol related patterns

›Recent binge use

›Daily heavy use

›Withdrawal symptoms

Electrolyte linked intake

›Electrolyte related factors

›Poor oral intake

›Vomiting

›Diarrhea

›Excess diuretics or laxatives

05Review of Systems/ros25

Cardiopulmonary

›Cardiopulmonary symptoms

›Chest pain

›Dyspnea

›Orthopnea

›PND symptoms

›Leg swelling

›Exercise intolerance

Neurologic

›Neurologic symptoms

›Syncope

›Presyncope

›Focal weakness

›Speech disturbance

›Visual disturbance

Endocrine and systemic

›Systemic symptoms

›Fever

›Weight loss

›Heat intolerance

›Tremor

›Night sweats

Bleeding and clot symptoms

›Thrombosis and bleeding signals

›Hemoptysis

›Pleuritic pain

›Unilateral leg pain

›Melena

›Heavy menstrual bleeding

06Collateral History and Family History/chafh14

Collateral source

›Collateral reliability

›Witnessed episode account

›EMS rhythm strip availability

›Family or caregiver corroboration

Family cardiac history

›Familial cardiovascular conditions

›Sudden unexplained death before age 50

›Cardiomyopathy history

›Long QT syndrome history

›Brugada syndrome history

›WPW history

Social support and follow up reliability

›Follow up feasibility

›Ability to return if symptoms recur

›Access to primary care

›Access to cardiology

07Risk Factors/rf22

Cardiac and arrhythmia risk

›Cardiac risk factors

›Coronary artery disease history

›Heart failure history

›Valvular disease history

›Congenital heart disease history

›Prior myocarditis history

Thromboembolism risk

›VTE risk factors

›Recent immobilization

›Recent surgery

›Active malignancy

›Estrogen therapy

›Prior VTE history

Substance and exposure risk

›Exposures

›Cocaine exposure

›Amphetamine exposure

›Excess caffeine exposure

›Nicotine exposure

Special populations

›Population modifiers

›Pregnancy

›Postpartum

›Older adult frailty

›Pediatric congenital heart disease

08Differential Diagnosis/ddx51

Life threatening

›Life threatening causes

›Ventricular tachycardia (I47.2)

›Structural heart disease context

›Wide complex tachycardia until proven otherwise

›Supraventricular tachycardia with instability (I47.1)

›Hypotension

›Ischemic chest pain

›Atrial fibrillation with RVR (I48.91)

›Heart failure decompensation

›Stroke symptoms

›Pulmonary embolism (I26.99)

›Pleuritic pain

›Hypoxia

›Acute coronary syndrome (I21.9)

›Ischemic ECG changes

›Troponin rise

›Hyperkalemia with arrhythmia risk (E87.5)

›Peaked T waves

›QRS widening

Common

›Common causes

›PAC or PVC ectopy (I49.3)

›Brief skipped beats

›Normal vitals between episodes

›AVNRT (I47.1)

›Sudden onset and termination

›Regular narrow complex tachycardia

›Atrial flutter (I48.92)

›Sawtooth flutter waves

›Ventricular rate around 150 per minute

›Sinus tachycardia (R00.0)

›Trigger present

›Gradual onset and offset

›Anxiety or panic (F41.0)

›Hyperventilation symptoms

›Situational trigger

Less common

›Less common causes

›WPW with AVRT (I45.6)

›Preexcitation pattern

›Very rapid irregular wide complex in AF

›Long QT related torsades risk (I45.81)

›QT prolongation

›Syncope episodes

›Brugada syndrome (I49.8)

›Coved ST elevation V1 to V3

›No alternative explanation

›Thyrotoxicosis (E05.90)

›Tremor

›Weight loss

›Myocarditis (I40.9)

›Viral prodrome

›Troponin elevation

09Past Medical History/pmh16

Cardiac history

›Cardiac conditions

›Prior atrial fibrillation or flutter

›Prior SVT diagnosis

›Prior VT diagnosis

›Prior syncope evaluation

Structural disease and procedures

›Structural and procedural history

›Cardiomyopathy

›Valve disease

›Prior ablation

›Prior cardioversion

›Pacemaker or ICD present

Non cardiac contributors

›Relevant comorbidities

›Thyroid disease

›Chronic lung disease

›Chronic kidney disease

›Diabetes mellitus (E11.9)

10Physical Exam/exam22

General and hemodynamics

›Global assessment

›Toxic appearance

›Work of breathing

›Perfusion

›Mental status

Cardiovascular

›Cardiac exam

›Rhythm regularity

›Murmur

›Signs of heart failure

›JVP elevation

Respiratory

›Lung exam

›Rales

›Wheeze

›Asymmetric breath sounds

Volume status

›Volume assessment

›Dry mucous membranes

›Orthostatic vitals pattern

›Peripheral edema

Neurologic and stroke screen

›Neurologic assessment

›Focal deficits

›Speech abnormality

›Gait instability

11Lab Studies/labs19

Core labs and rationale

›Essential labs

›CBC for anemia or infection

›Electrolytes for K and Mg abnormalities

›Creatinine for renal function and dosing

›Glucose for hypoglycemia or hyperglycemia

Cardiac biomarkers

›Myocardial injury testing

›Troponin when chest pain

›Troponin when ischemic ECG changes

›Troponin when myocarditis concern

Endocrine and metabolic

›Endocrine evaluation

›TSH when new atrial fibrillation

›Pregnancy test when pregnancy possible

Coagulation and anticoagulant context

›Coagulation context

›INR if warfarin use

›Anti Xa or drug specific level local protocol dependent

Limitations and pitfalls

›Interpretation pitfalls

›Normal troponin early in ACS

›Hemolysis causing false hyperkalemia

›Hypomagnesemia with normal potassium possible

12Imaging/img31

Scoring Systems

›Decision tools for palpitations context

›CHA2DS2 VASc for atrial fibrillation stroke risk

›Use for long term anticoagulation planning

›Not for ED decision to anticoagulate immediately in most cases

›HAS BLED for bleeding risk context

›Use to identify modifiable bleeding risks

›Not a reason alone to withhold anticoagulation

›Wells score for pulmonary embolism probability

›Use when PE features present

›Combine with D dimer when low to intermediate probability

MRI

›MRI indications

›Cardiac MRI for myocarditis or cardiomyopathy characterization

›Brain MRI for TIA workup local protocol dependent

›MRI limitations

›Limited ED availability

›Implanted device compatibility constraints

›CT indications

›CT pulmonary angiography for suspected PE

›CT head for syncope with head trauma

›Coronary CT angiography for low to intermediate risk chest pain local protocol dependent

›CT safety considerations

›IV contrast nephropathy risk context

›Contrast allergy history

›Radiation risk in pregnancy

Ultrasound

›POCUS applications

›Cardiac POCUS for pericardial effusion

›Cardiac POCUS for gross LV dysfunction

›Lung POCUS for pulmonary edema pattern

›Ultrasound limitations

›Operator dependence

›Limited sensitivity for small PE

13Special Tests/spec8

Bedside maneuvers and monitoring

›Bedside options

›Vagal maneuvers for stable regular narrow complex SVT

›Modified Valsalva technique when feasible

›Orthostatic vitals for volume depletion pattern

Rhythm capture strategies

›Rhythm documentation

›Continuous cardiac monitoring in ED

›Serial 12 lead ECG during symptoms

›Ambulatory monitor referral for intermittent symptoms

14ECG/ecg19

Indications and timing

›ECG workflow

›Immediate 12 lead ECG for active palpitations

›ECG within 10 minutes if chest pain present

›Repeat ECG with symptom recurrence

Rhythm diagnosis patterns

›Narrow complex tachycardia

›Regular narrow complex consistent with SVT

›Irregular narrow complex consistent with atrial fibrillation

›Wide complex tachycardia

›Treat as ventricular tachycardia until proven otherwise

›SVT with aberrancy as alternate diagnosis

High risk patterns

›ECG danger patterns

›Preexcited atrial fibrillation

›QTc prolongation pattern

›Brugada pattern

›Ischemic ST changes

AV conduction and brady features

›Conduction abnormalities

›High grade AV block

›Sinus pauses

›Bifascicular block

15Assessment/ax20

Severity stratification

›Stability determination

›Unstable features

›Stable with symptoms only

›Asymptomatic tachyarrhythmia found incidentally

Working diagnosis framing

›Rhythm based diagnosis

›Atrial fibrillation or flutter with RVR

›Onset time known or unknown

›Stroke risk context

›Regular narrow complex SVT

›Likely AVNRT

›Likely AVRT

›Wide complex tachycardia

›Ventricular tachycardia favored

›Toxicologic causes considered

Alternative diagnoses and mimics

›Mimics and contributors

›Sinus tachycardia triggers

›Ectopy

›Anxiety

›Anemia

›Thyrotoxicosis

16Plan/plan57

First 5 minutes

›Immediate workflow

›Airway and oxygenation support if hypoxic

›Continuous cardiac monitoring

›IV access

›12 lead ECG

›Point of care glucose

Unstable tachyarrhythmia pathway

›Unstable management

›Synchronized cardioversion

›Narrow regular 50 to 100 J biphasic local protocol dependent

›Narrow irregular 120 to 200 J biphasic local protocol dependent

›Wide regular 100 J biphasic local protocol dependent

›Sedation if time allows

›Etomidate IV 0.15 mg per kg

›Ketamine IV 0.5 to 1 mg per kg

Stable regular narrow complex SVT

›SVT stable management

›Vagal maneuvers

›Modified Valsalva preferred when feasible

›Carotid sinus massage avoided in carotid disease history

›Adenosine if no contraindication

›IV 6 mg rapid push with flush

›If no conversion, IV 12 mg rapid push

›Contraindications

›Severe asthma

›Heart transplant

›Preexcited atrial fibrillation concern

Atrial fibrillation or flutter with RVR

›Rate control strategy

›Diltiazem IV 0.25 mg per kg

›If needed, IV 0.35 mg per kg after 15 minutes

›Metoprolol IV 2.5 to 5 mg every 5 minutes

›Maximum 15 mg

›Avoid AV nodal blockers in preexcited atrial fibrillation

›Rhythm control considerations local protocol dependent

›Cardioversion when onset clearly less than 48 hours and low thrombus risk

›Anticoagulation strategy when onset unknown

Wide complex tachycardia stable

›Wide complex stable approach

›Amiodarone IV 150 mg over 10 minutes

›Repeat as needed to maximum 2.2 g in 24 hours local protocol dependent

›Procainamide IV 20 to 50 mg per minute until termination

›Maximum 17 mg per kg

›Avoid procainamide in severe heart failure

Electrolyte correction

›Electrolyte optimization

›Potassium repletion when low

›Target potassium greater than 4.0 mmol per L in arrhythmia risk context

›Route and rate per local protocol

›Magnesium repletion when low or torsades risk

›Magnesium sulfate IV 2 g

›Repeat dosing local protocol dependent

Anticoagulation considerations

›Stroke prevention framework

›Anticoagulation initiation local protocol dependent

›Contraindications screening

›Active bleeding

›Intracranial hemorrhage history high risk context

Reassessment loop

›Reassessment cadence

›Repeat vitals every 15 to 30 minutes until stable

›Rhythm recheck after each intervention

›Symptom reassessment after rate or rhythm control

›Disposition reassessment after lab results and ECG trend

17Disposition/dispo23

ICU and monitored care

›ICU criteria

›Recurrent instability

›Sustained VT

›Ongoing ischemia

›Shock requiring vasopressors

›Monitored admission criteria

›New atrial fibrillation with ongoing RVR

›Need for IV rate control infusion

›Syncope with abnormal ECG

›Troponin rise consistent with ACS or myocarditis

Observation pathway

›Observation candidates

›Rate control achieved but needs monitoring for recurrence

›Serial troponin and ECG for chest pain low to intermediate risk

Discharge criteria

›Discharge requirements

›Hemodynamic stability

›Symptom resolution or acceptable baseline

›No high risk ECG features

›No concerning lab abnormalities requiring inpatient correction

›Reliable follow up within 72 hours when new arrhythmia

Follow up timing

›Follow up plan

›Cardiology referral for new atrial fibrillation or suspected SVT

›Ambulatory monitor arrangement for intermittent symptoms

›Primary care follow up for trigger management and medication review

18Discharge Instructions/di24

Copy discharge instructions

›Patient instructions

›Palpitations evaluated today

›Heart rhythm today did not show an immediately dangerous cause

›Avoid triggers

›Caffeine

›Energy drinks

›Dehydration

›Stimulants

›Medications

›Take as prescribed

›Do not double doses if missed

›Avoid over the counter decongestants unless cleared

›Activity

›No driving if fainting occurred until cleared

›Gradual return to activity if symptoms resolved

›Follow up

›Follow up within 2 to 3 days

›Cardiology follow up if arranged

›Return to ED now for

›Chest pain

›Trouble breathing

›Fainting

›New weakness or speech trouble

›Palpitations lasting more than 20 minutes with symptoms

19References/r6

Guidelines and tools

›Evidence sources

›American Heart Association ACLS Guidelines 2020

›ACC AHA HRS Guideline for the Management of Atrial Fibrillation 2023

›ESC Guidelines for the Management of Atrial Fibrillation 2024

›2019 ESC Guidelines for Supraventricular Tachycardia 2019

›CHA2DS2 VASc risk score validation literature

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Palpitations and Tachyarrhythmia SymptomsAPPROACH

CHEST AND CARDIOVASCULAR · 19 SECTIONS

⚲

491 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx69

Presenting pattern

›Pattern overview

›Palpitations description

›Tachycardia sensation

›Irregular heartbeat sensation

›Skipped beats sensation

›Fluttering sensation

OPQRST

›O onset

›Sudden onset

›Gradual onset

›First episode

›Recurrent episodes

›P provocation and palliation

›Exertion related

›Rest related

›Position related

›Valsalva related

›Caffeine related

›Alcohol related

›Stimulant related

›Stress related

›Q quality

›Regular rapid

›Irregular rapid

›Thumping

›Pounding

›Pauses

›R region and radiation

›Chest awareness

›Neck pulsations

›Throat pounding

›S severity

›Functional limitation

›Activity interruption

›Associated presyncope

›T timing

›Episode duration

›Frequency

›Time of day pattern

›Abrupt termination

›Trigger reproducibility

Associated symptoms

›Associated symptoms cluster

›Chest pain

›Dyspnea

›Syncope

›Presyncope

›Dizziness

›Diaphoresis

›Nausea

›Neurologic deficit symptoms

›Fever

Prior episodes and baseline

›Baseline comparison

›Prior similar episodes

›Prior ECG findings known

›Prior arrhythmia diagnosis

›Prior ablation

›Prior cardioversion

Context and triggers

›Contextual factors

›Recent illness

›Dehydration

›Sleep deprivation

›Pain

›Anxiety or panic symptoms

›Pregnancy or postpartum status

›Recent surgery

›Recent immobilization

Rhythm capture history

›Prior rhythm documentation

›Prior Holter or patch monitor results

›Prior wearable device tracings

›Event monitor correlation with symptoms

02Alarm Features/alarm28

Immediate life threats

›High risk presentations

›Syncope during palpitations

›Chest pain with palpitations

›Dyspnea with hypoxia

›Altered mental status

›Shock physiology

›Sustained wide complex tachycardia

Vital sign danger thresholds

›High risk vitals

›Systolic blood pressure less than 90 mmHg

›Heart rate greater than 150 per minute with symptoms

›Oxygen saturation less than 90 percent on room air

›Respiratory rate greater than 30 per minute

High risk history triggers

›High risk history

›Known structural heart disease

›Known ventricular arrhythmia history

›Inherited arrhythmia syndrome history

›Family history sudden unexplained death

›Recent stimulant or cocaine exposure

High risk ECG features

›ECG red flags

›Preexcitation pattern

›QTc prolongation

›Brugada pattern

›Ischemic changes

›High grade AV block

Escalation triggers

›Escalation criteria

›If unstable, synchronized cardioversion

›If pulseless, cardiac arrest algorithm

›If ongoing ischemia, emergent cardiology activation

03Medications/meds23

Medication reconciliation

›Current medications

›Beta blockers

›Calcium channel blockers

›Antiarrhythmics

›Anticoagulants

›Thyroid hormone

›Diuretics

Arrhythmogenic medications

›Medication risk exposures

›QT prolonging agents

›Sympathomimetics

›ADHD stimulants

›Decongestants

›Bronchodilators

Recent changes and adherence

›Medication course

›Recent dose changes

›Missed doses

›Recent discontinuation

›Recent initiation

Drug interactions and contraindications

›Interaction hazards

›AV nodal blocker stacking

›QT prolongation combinations

›CYP interactions with antiarrhythmics

›Anticoagulant interactions

04Diet/diet14

Stimulants and hydration

›Dietary contributors

›Caffeine intake pattern

›Energy drinks

›Pre workout supplements

›Hydration deficit

Alcohol and withdrawal

›Alcohol related patterns

›Recent binge use

›Daily heavy use

›Withdrawal symptoms

Electrolyte linked intake

›Electrolyte related factors

›Poor oral intake

›Vomiting

›Diarrhea

›Excess diuretics or laxatives

05Review of Systems/ros25

Cardiopulmonary

›Cardiopulmonary symptoms

›Chest pain

›Dyspnea

›Orthopnea

›PND symptoms

›Leg swelling

›Exercise intolerance

Neurologic

›Neurologic symptoms

›Syncope

›Presyncope

›Focal weakness

›Speech disturbance

›Visual disturbance

Endocrine and systemic

›Systemic symptoms

›Fever

›Weight loss

›Heat intolerance

›Tremor

›Night sweats

Bleeding and clot symptoms

›Thrombosis and bleeding signals

›Hemoptysis

›Pleuritic pain

›Unilateral leg pain

›Melena

›Heavy menstrual bleeding

06Collateral History and Family History/chafh14

Collateral source

›Collateral reliability

›Witnessed episode account

›EMS rhythm strip availability

›Family or caregiver corroboration

Family cardiac history

›Familial cardiovascular conditions

›Sudden unexplained death before age 50

›Cardiomyopathy history

›Long QT syndrome history

›Brugada syndrome history

›WPW history

Social support and follow up reliability

›Follow up feasibility

›Ability to return if symptoms recur

›Access to primary care

›Access to cardiology

07Risk Factors/rf22

Cardiac and arrhythmia risk

›Cardiac risk factors

›Coronary artery disease history

›Heart failure history

›Valvular disease history

›Congenital heart disease history

›Prior myocarditis history

Thromboembolism risk

›VTE risk factors

›Recent immobilization

›Recent surgery

›Active malignancy

›Estrogen therapy

›Prior VTE history

Substance and exposure risk

›Exposures

›Cocaine exposure

›Amphetamine exposure

›Excess caffeine exposure

›Nicotine exposure

Special populations

›Population modifiers

›Pregnancy

›Postpartum

›Older adult frailty

›Pediatric congenital heart disease

08Differential Diagnosis/ddx51

Life threatening

›Life threatening causes

›Ventricular tachycardia (I47.2)

›Structural heart disease context

›Wide complex tachycardia until proven otherwise

›Supraventricular tachycardia with instability (I47.1)

›Hypotension

›Ischemic chest pain

›Atrial fibrillation with RVR (I48.91)

›Heart failure decompensation

›Stroke symptoms

›Pulmonary embolism (I26.99)

›Pleuritic pain

›Hypoxia

›Acute coronary syndrome (I21.9)

›Ischemic ECG changes

›Troponin rise

›Hyperkalemia with arrhythmia risk (E87.5)

›Peaked T waves

›QRS widening

Common

›Common causes

›PAC or PVC ectopy (I49.3)

›Brief skipped beats

›Normal vitals between episodes

›AVNRT (I47.1)

›Sudden onset and termination

›Regular narrow complex tachycardia

›Atrial flutter (I48.92)

›Sawtooth flutter waves

›Ventricular rate around 150 per minute

›Sinus tachycardia (R00.0)

›Trigger present

›Gradual onset and offset

›Anxiety or panic (F41.0)

›Hyperventilation symptoms

›Situational trigger

Less common

›Less common causes

›WPW with AVRT (I45.6)

›Preexcitation pattern

›Very rapid irregular wide complex in AF

›Long QT related torsades risk (I45.81)

›QT prolongation

›Syncope episodes

›Brugada syndrome (I49.8)

›Coved ST elevation V1 to V3

›No alternative explanation

›Thyrotoxicosis (E05.90)

›Tremor

›Weight loss

›Myocarditis (I40.9)

›Viral prodrome

›Troponin elevation

09Past Medical History/pmh16

Cardiac history

›Cardiac conditions

›Prior atrial fibrillation or flutter

›Prior SVT diagnosis

›Prior VT diagnosis

›Prior syncope evaluation

Structural disease and procedures

›Structural and procedural history

›Cardiomyopathy

›Valve disease

›Prior ablation

›Prior cardioversion

›Pacemaker or ICD present

Non cardiac contributors

›Relevant comorbidities

›Thyroid disease

›Chronic lung disease

›Chronic kidney disease

›Diabetes mellitus (E11.9)

10Physical Exam/exam22

General and hemodynamics

›Global assessment

›Toxic appearance

›Work of breathing

›Perfusion

›Mental status

Cardiovascular

›Cardiac exam

›Rhythm regularity

›Murmur

›Signs of heart failure

›JVP elevation

Respiratory

›Lung exam

›Rales

›Wheeze

›Asymmetric breath sounds

Volume status

›Volume assessment

›Dry mucous membranes

›Orthostatic vitals pattern

›Peripheral edema

Neurologic and stroke screen

›Neurologic assessment

›Focal deficits

›Speech abnormality

›Gait instability

11Lab Studies/labs19

Core labs and rationale

›Essential labs

›CBC for anemia or infection

›Electrolytes for K and Mg abnormalities

›Creatinine for renal function and dosing

›Glucose for hypoglycemia or hyperglycemia

Cardiac biomarkers

›Myocardial injury testing

›Troponin when chest pain

›Troponin when ischemic ECG changes

›Troponin when myocarditis concern

Endocrine and metabolic

›Endocrine evaluation

›TSH when new atrial fibrillation

›Pregnancy test when pregnancy possible

Coagulation and anticoagulant context

›Coagulation context

›INR if warfarin use

›Anti Xa or drug specific level local protocol dependent

Limitations and pitfalls

›Interpretation pitfalls

›Normal troponin early in ACS

›Hemolysis causing false hyperkalemia

›Hypomagnesemia with normal potassium possible

12Imaging/img31

Scoring Systems

›Decision tools for palpitations context

›CHA2DS2 VASc for atrial fibrillation stroke risk

›Use for long term anticoagulation planning

›Not for ED decision to anticoagulate immediately in most cases

›HAS BLED for bleeding risk context

›Use to identify modifiable bleeding risks

›Not a reason alone to withhold anticoagulation

›Wells score for pulmonary embolism probability

›Use when PE features present

›Combine with D dimer when low to intermediate probability

MRI

›MRI indications

›Cardiac MRI for myocarditis or cardiomyopathy characterization

›Brain MRI for TIA workup local protocol dependent

›MRI limitations

›Limited ED availability

›Implanted device compatibility constraints

›CT indications

›CT pulmonary angiography for suspected PE

›CT head for syncope with head trauma

›Coronary CT angiography for low to intermediate risk chest pain local protocol dependent

›CT safety considerations

›IV contrast nephropathy risk context

›Contrast allergy history

›Radiation risk in pregnancy

Ultrasound

›POCUS applications

›Cardiac POCUS for pericardial effusion

›Cardiac POCUS for gross LV dysfunction

›Lung POCUS for pulmonary edema pattern

›Ultrasound limitations

›Operator dependence

›Limited sensitivity for small PE

13Special Tests/spec8

Bedside maneuvers and monitoring

›Bedside options

›Vagal maneuvers for stable regular narrow complex SVT

›Modified Valsalva technique when feasible

›Orthostatic vitals for volume depletion pattern

Rhythm capture strategies

›Rhythm documentation

›Continuous cardiac monitoring in ED

›Serial 12 lead ECG during symptoms

›Ambulatory monitor referral for intermittent symptoms

14ECG/ecg19

Indications and timing

›ECG workflow

›Immediate 12 lead ECG for active palpitations

›ECG within 10 minutes if chest pain present

›Repeat ECG with symptom recurrence

Rhythm diagnosis patterns

›Narrow complex tachycardia

›Regular narrow complex consistent with SVT

›Irregular narrow complex consistent with atrial fibrillation

›Wide complex tachycardia

›Treat as ventricular tachycardia until proven otherwise

›SVT with aberrancy as alternate diagnosis

High risk patterns

›ECG danger patterns

›Preexcited atrial fibrillation

›QTc prolongation pattern

›Brugada pattern

›Ischemic ST changes

AV conduction and brady features

›Conduction abnormalities

›High grade AV block

›Sinus pauses

›Bifascicular block

15Assessment/ax20

Severity stratification

›Stability determination

›Unstable features

›Stable with symptoms only

›Asymptomatic tachyarrhythmia found incidentally

Working diagnosis framing

›Rhythm based diagnosis

›Atrial fibrillation or flutter with RVR

›Onset time known or unknown

›Stroke risk context

›Regular narrow complex SVT

›Likely AVNRT

›Likely AVRT

›Wide complex tachycardia

›Ventricular tachycardia favored

›Toxicologic causes considered

Alternative diagnoses and mimics

›Mimics and contributors

›Sinus tachycardia triggers

›Ectopy

›Anxiety

›Anemia

›Thyrotoxicosis

16Plan/plan57

First 5 minutes

›Immediate workflow

›Airway and oxygenation support if hypoxic

›Continuous cardiac monitoring

›IV access

›12 lead ECG

›Point of care glucose

Unstable tachyarrhythmia pathway

›Unstable management

›Synchronized cardioversion

›Narrow regular 50 to 100 J biphasic local protocol dependent

›Narrow irregular 120 to 200 J biphasic local protocol dependent

›Wide regular 100 J biphasic local protocol dependent

›Sedation if time allows

›Etomidate IV 0.15 mg per kg

›Ketamine IV 0.5 to 1 mg per kg

Stable regular narrow complex SVT

›SVT stable management

›Vagal maneuvers

›Modified Valsalva preferred when feasible

›Carotid sinus massage avoided in carotid disease history

›Adenosine if no contraindication

›IV 6 mg rapid push with flush

›If no conversion, IV 12 mg rapid push

›Contraindications

›Severe asthma

›Heart transplant

›Preexcited atrial fibrillation concern

Atrial fibrillation or flutter with RVR

›Rate control strategy

›Diltiazem IV 0.25 mg per kg

›If needed, IV 0.35 mg per kg after 15 minutes

›Metoprolol IV 2.5 to 5 mg every 5 minutes

›Maximum 15 mg

›Avoid AV nodal blockers in preexcited atrial fibrillation

›Rhythm control considerations local protocol dependent

›Cardioversion when onset clearly less than 48 hours and low thrombus risk

›Anticoagulation strategy when onset unknown

Wide complex tachycardia stable

›Wide complex stable approach

›Amiodarone IV 150 mg over 10 minutes

›Repeat as needed to maximum 2.2 g in 24 hours local protocol dependent

›Procainamide IV 20 to 50 mg per minute until termination

›Maximum 17 mg per kg

›Avoid procainamide in severe heart failure

Electrolyte correction

›Electrolyte optimization

›Potassium repletion when low

›Target potassium greater than 4.0 mmol per L in arrhythmia risk context

›Route and rate per local protocol

›Magnesium repletion when low or torsades risk

›Magnesium sulfate IV 2 g

›Repeat dosing local protocol dependent

Anticoagulation considerations

›Stroke prevention framework

›Anticoagulation initiation local protocol dependent

›Contraindications screening

›Active bleeding

›Intracranial hemorrhage history high risk context

Reassessment loop

›Reassessment cadence

›Repeat vitals every 15 to 30 minutes until stable

›Rhythm recheck after each intervention

›Symptom reassessment after rate or rhythm control

›Disposition reassessment after lab results and ECG trend

17Disposition/dispo23

ICU and monitored care

›ICU criteria

›Recurrent instability

›Sustained VT

›Ongoing ischemia

›Shock requiring vasopressors

›Monitored admission criteria

›New atrial fibrillation with ongoing RVR

›Need for IV rate control infusion

›Syncope with abnormal ECG

›Troponin rise consistent with ACS or myocarditis

Observation pathway

›Observation candidates

›Rate control achieved but needs monitoring for recurrence

›Serial troponin and ECG for chest pain low to intermediate risk

Discharge criteria

›Discharge requirements

›Hemodynamic stability

›Symptom resolution or acceptable baseline

›No high risk ECG features

›No concerning lab abnormalities requiring inpatient correction

›Reliable follow up within 72 hours when new arrhythmia

Follow up timing

›Follow up plan

›Cardiology referral for new atrial fibrillation or suspected SVT

›Ambulatory monitor arrangement for intermittent symptoms

›Primary care follow up for trigger management and medication review

18Discharge Instructions/di24

Copy discharge instructions

›Patient instructions

›Palpitations evaluated today

›Heart rhythm today did not show an immediately dangerous cause

›Avoid triggers

›Caffeine

›Energy drinks

›Dehydration

›Stimulants

›Medications

›Take as prescribed

›Do not double doses if missed

›Avoid over the counter decongestants unless cleared

›Activity

›No driving if fainting occurred until cleared

›Gradual return to activity if symptoms resolved

›Follow up

›Follow up within 2 to 3 days

›Cardiology follow up if arranged

›Return to ED now for

›Chest pain

›Trouble breathing

›Fainting

›New weakness or speech trouble

›Palpitations lasting more than 20 minutes with symptoms

19References/r6

Guidelines and tools

›Evidence sources

›American Heart Association ACLS Guidelines 2020

›ACC AHA HRS Guideline for the Management of Atrial Fibrillation 2023

›ESC Guidelines for the Management of Atrial Fibrillation 2024

›2019 ESC Guidelines for Supraventricular Tachycardia 2019

›CHA2DS2 VASc risk score validation literature

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.