Tag: palpitations

Tachycardia

Adult ED Management – RCUK 2025

Treat the patient, not the rate

Sinus tachycardia is usually compensatory — identify and treat the cause. Do NOT cardiovert sinus tachycardia.

INITIAL ASSESSMENT

ABCDE

Cardiac monitor
BP and SpO₂
12-lead ECG
IV access
Bloods as clinically indicated: FBC
U&E / Mg²⁺ / Ca²⁺
glucose
troponin where indicated
other investigations directed by likely cause
Give oxygen only if SpO₂ <94%, unless an alternative target is appropriate.

Think WHY the patient is tachycardic?

Sepsis/Hypovolaemia/Haemorrhage
Pain/Anxiety
Hypoxia
Fever
PE
ACS/Heart failure
Thyrotoxicosis
Drugs/Withdrawal
Pregnancy

Do not attempt to normalise an appropriate sinus tachycardia with anti-arrhythmics or electrical cardioversion.

SIMPLE ED RULE

SICK? → SHOCK

WELL? → WIDTH + REGULARITY

  • Narrow + regular: Vagal → Adenosine → Verapamil / beta-blocker → Shock
  • Narrow + irregular: AF pathway / rate control
  • Broad + regular: VT until proven otherwise → Cardioversion / procainamide
  • Broad + irregular: Pre-excited AF / polymorphic VT → expert help

UNSTABLE?

LIFE-THREATENING FEATURES

> SHOCK: Hypotension with evidence of impaired tissue perfusion.
> SYNCOPE: Especially with severe or ongoing hypotension.
> MYOCARDIAL ISCHAEMIA: Ongoing chest pain and/or significant ischaemic ECG changes.
> SEVERE HEART FAILURE: Particularly pulmonary oedema.
> IMMEDIATELY POST-ROSC

DC-Cardiversion (SYNC) RCUK 2025

> AF → Maximum defibrillator output
> Flutter / SVT → 70–120 J
> VT with pulse → 120–150 J

Escalate subsequent shocks where appropriate.

STABLE

Regular  – Sinus Tachycardia, AVNRT (SVT), Atrial flutter with regular block, AVRT (WPW)

  • Sinus Tachycardia – Look for the cause ?infection ?pain ?anaemia ?hypovolaemia ?anxiety ?drugs
  • SVT – Stepwise treatment until NSR regained (ensure cardiac monitoring): –
    • Vagal Manoeuvres – Lie flat and head down, Carotid sinus massage (ensure no bruit 1st), Blow into 50ml syringe
    • Adenosine –  6mg, 12mg, 18mg boluses (not in severe Asthma/Allergy/Heart transplant)
    • Not reverted – call for expert help
  • Atrial Flutter with 2:1 block (150bpm) – consider rate controlling drugs
  • AVRT (WPW) – get expert help (DO NOT give Adenosine)

PDF: Arrhythmia Clinic referral form (Print and Fax OR can email – use fill and sign function to enter details)

PDF: Patient Info

Irregular – likely AF (Follow AF Pathway)

Assume VT until proven otherwise

Particularly in:

  • older patients
  • previous MI
  • structural heart disease
  • cardiomyopathy

Stable monomorphic VT

Electrical cardioversion is an appropriate first-line strategy

  • Especially where structural heart disease is present or cannot be excluded.
  • SYNCHRONISED CARDIOVERSION For VT with a pulse: 120–150 J initially, escalating if required

If sedation / anaesthesia presents significant risk

Drug treatment may be considered:

  • Procainamide 10–15 mg/kg IV over 20 minutes Maximum 1 g OR
  • Amiodarone 300 mg IV over 10–60 minutes followed by: 900 mg IV over 24 hours
  • If ineffective: SYNCHRONISED CARDIOVERSION WITH EXPERT ADVICE

STOP — HIGH-RISK RHYTHM

Consider:

  • 1. AF WITH BUNDLE BRANCH BLOCK
  • 2. PRE-EXCITED AF / WPW
  • 3. POLYMORPHIC VT

Seek senior / cardiology support early.

PRE-EXCITED AF

Think pre-excitation when there is:

  • very rapid irregular broad-complex tachycardia
  • varying QRS morphology
  • ventricular rates sometimes >200 bpm
  • known WPW / previous delta wave

DO NOT GIVE AV-NODAL BLOCKING DRUGS

Avoid the following as these may increase conduction through the accessory pathway and precipitate VF:

  • Adenosine
  • Beta-blockers
  • Verapamil
  • Diltiazem
  • Digoxin

Treatment

  • Procainamide OR
  • Synchronised cardioversion

If polymorphic VT occurs with QT prolongation:

Magnesium: Mg²⁺ 8 mmol IV over 10 minutes

Also:

  • Correct K⁺ / Mg²⁺ abnormalities.
  • Stop QT-prolonging drugs.
  • Treat reversible causes.
  • Seek expert help.

For recurrent pause-dependent torsades consider increasing the heart rate with:

  • Isoprenaline OR
  • Temporary pacing

❌ AVOID AMIODARONE because it may further prolong the QT interval.

⚠️ PITFALLS

FAST ≠ ARRHYTHMIA

Do not treat physiological sinus tachycardia as an arrhythmia.

BROAD + REGULAR = VT UNTIL PROVEN OTHERWISE

Do not delay appropriate treatment while attempting to prove SVT.

BROAD + IRREGULAR ≠ ROUTINE AF

Always consider pre-excited AF.

ADENOSINE IS NOT FOR IRREGULAR BROAD-COMPLEX TACHYCARDIA

DO NOT GIVE AMIODARONE FOR TORSADES / LONG-QT POLYMORPHIC VT

Give magnesium and correct the underlying problem.

CARDIOVERSION REQUIRES SYNC

Confirm the machine is marking the R waves before delivering the shock.

Re-check SYNC after each shock — some defibrillators automatically revert out of synchronised mode.

DISPOSITION

Consider admission / cardiology assessment for:

  • VT
  • broad-complex tachycardia of uncertain cause
  • syncope associated with tachyarrhythmia
  • significant structural heart disease
  • ACS / myocardial ischaemia
  • heart failure
  • recurrent arrhythmia despite treatment
  • pre-excitation
  • significant electrolyte disturbance
  • drug-induced arrhythmia
  • prolonged QT / torsades
  • haemodynamic instability
  • arrhythmia requiring electrical cardioversion

Patients with uncomplicated successfully terminated SVT may be suitable for discharge following senior review, appropriate investigation and follow-up depending on the clinical circumstances.

GUIDANCE

Based primarily on:

  • Resuscitation Council UK — Guidelines 2025: Adult Advanced Life Support
  • Resuscitation Council UK — Adult Tachyarrhythmia Algorithm, current version March 2026
  • Current atrial fibrillation guidance

EMbeds clinical quick guide

Last evidence review: September 2026
Suggested next review: September 2027

This is a clinical support guide and does not replace clinical judgement, current CHFT medicines guidance or specialist advice.