Onset/offset, regularity, duration, exertional or supine symptoms
Syncope, chest pain, dyspnea, neurologic symptoms, family history of sudden death
Stimulants, alcohol, supplements, medications, thyroid disease, prior ECG/device
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← All presentations
Palpitations & Dysrhythmia
Capture the rhythm, then decide whether the patient or the ECG is unstable.
Your objective: explain the approach, recognize important warning signs, then test your recall.
Abbreviations explained
- ACS
- Acute coronary syndrome
- OMI
- Occlusion myocardial infarction
- ECG
- Electrocardiogram
- PE
- Pulmonary embolism
- POCUS
- Point-of-care ultrasound
- QTc
- QT interval corrected for heart rate
- LBBB
- Left bundle branch block
- RBBB
- Right bundle branch block
- hs-cTn
- High-sensitivity cardiac troponin
- CTA
- Computed tomography angiography
- ICU
- Intensive care unit
Filter
The jobCapture the rhythm, then decide whether the patient or the ECG is unstable.
- ABCs, monitor, IV access and 12-lead ECG; treat instability immediately.
- Classify regular versus irregular and narrow versus wide only after checking the patient.
- Search for ischemia, electrolyte disturbance, thyroid disease, stimulant use, structural disease, and inherited-risk clues.
Palpitations range from benign ectopy to a rhythm causing shock, ischemia, heart failure, or syncope.
The first ECG and a strip during symptoms are more valuable than retrospective labels.
Unstable tachyarrhythmia or bradyarrhythmia Critical
Key: Hypotension, shock, ischemic pain, pulmonary edema, or altered mentation means immediate resuscitation per local ACLS protocol.
Ventricular tachycardia Critical
Key: Assume wide-complex tachycardia is VT until expert review proves otherwise.
Pre-excited atrial fibrillation Critical
Key: Irregular wide-complex rhythm may deteriorate rapidly; avoid AV-nodal blockers and IV amiodarone; unstable patients need cardioversion, stable patients need expert procainamide/ibutilide or cardioversion assessment.
ACS, PE, dissection, or toxicologic cause Emergent
Key: Palpitations may be the presenting symptom of another time-critical illness.
Sinus tachycardia / ectopy Common
Key: A diagnosis of exclusion; explain and treat the driver rather than only the rate.
Tick what your patient has — the banner updates as you go.
Perfusion, blood pressure, mental status, heart-failure signs
Pulse regularity and rate; murmurs; volume status
Look for toxidrome, fever, anemia, or thyrotoxicosis clues
Immediate
- 12-lead ECG and continuous rhythm monitoring
- Glucose and targeted electrolytes; pregnancy test when relevant
Targeted
- Troponin when ischemia is possible; CBC, magnesium, TSH when clinically indicated
- POCUS/echo when structural disease, heart failure, or pericardial disease is suspected
Do not miss
- Obtain prior ECGs and device interrogation when available
- Ambulatory monitoring only after dangerous rhythm and structural disease are reasonably excluded
Medication safety reminder
Use this as a first-pass prompt; verify all medications, doses, concentrations, contraindications, weight, pregnancy status, and local protocols before administration.
Check indication, allergy, route, renal/hepatic risk, interactions, monitoring, and local formulary.
Discharge
- Resolved low-risk symptoms, reassuring ECG/assessment, no syncope or structural-risk features, and reliable follow-up.
Observation / telemetry
- Uncaptured recurrent symptoms, abnormal ECG, electrolyte correction, new AF, or uncertain cause.
Resuscitation / ICU / cardiology
- Unstable rhythm, VT, pre-excitation concern, high-grade block, ischemia, or decompensated heart failure.
Use objective reassessment and the local pathway.
Before the next decision · reassess and hand over
Use these learning prompts with the presentation’s pathway. They are not discharge criteria.
- Reassess: compare symptoms, observations and examination with the initial assessment and response to treatment.
- Warning signs for Palpitations & Dysrhythmia:
- Syncope or persistent hypotension
- Wide-complex or very rapid rhythm
- Chest pain, ischemic ECG changes, or acute heart failure
- Known structural heart disease or inherited-arrhythmia history
- Palpitations during exertion or with stimulant/toxin exposure
- Reconsider: check unresolved findings and alternative explanations, including the pitfalls below.
- Escalate: communicate deterioration, uncertainty or needs beyond the current setting.
- Plan the transition: identify outstanding results, responsibility for follow-up, patient understanding and specific return advice.
Clinical Pearls
- The patient’s perfusion determines urgency; the ECG defines the next branch.
- A rhythm strip during symptoms is often the diagnostic test.
Pitfalls
- Calling every fast rhythm anxiety before obtaining an ECG.
- Treating a wide rhythm as SVT without considering VT or pre-excitation.
PRACTICE REFRESHER
Rapid recall
Test your first action and the dangerous diagnoses before revealing the answer.
01 · First move
Before you scroll, what needs to happen first?
ABCs, monitor, IV access and 12-lead ECG; treat instability immediately.
02 · Immediate threats
Name at least two diagnoses that cannot wait.
Unstable tachyarrhythmia or bradyarrhythmia · Ventricular tachycardia · Pre-excited atrial fibrillation
PRIVATE TO THIS DEVICE
Your learning note
Capture a weak point, a teaching pearl, or a question to take to your next shift.
Review schedule starts when marked reviewed
Selected guidance · source check 2026-09-07. These 2 source links support selected teaching points, not a complete review of this topic. Check population, setting and local protocol before applying a recommendation.
- Rosen’s Emergency Medicine, 10th ed. — dysrhythmias
- AHA ACLS and ACC/AHA/HRS arrhythmia guidance; apply local protocols