Heart Rate – Tachycardia

ABCs
  • ABCs and vitals
  • Place on a cardiac monitor
  • If febrile / pain -> give Acetaminophen 1 g IV (max 4 g/day) and reassess
  • Signs of shock or hypoperfusion -> hypotension or altered LOC
HPI
  • Symptoms → Chest pain, dyspnea, palpitations, nausea, diaphoresis, presyncope, altered LOC
  • Triggers -> Pain, anxiety, hypovolemia, caffeine, new meds
  • History of arrhythmias
  • Review the treatment sheet
  • Suspect PE if tachypnea or oxygen desaturation
workup
  • ECG -> assess the rhythm / wide vs narrow QRS
  • Electrolytes K⁺, Mg²⁺, Ca²⁺
  • VBG + lactate
  • TSH (if indicated)
management
  • Stable patients
    • Treat reversible causes: sepsis, hypovolemia, pain, anxiety, medications, electrolyte disturbances
    • Optimize electrolytes (especially K⁺ and Mg²⁺)
    • If no overload or ESRD/HF -> IV fluids (500–1000 mL NS or RL)
  • Unstable or symptomatic with ECG changes
    • Manage based on cause: arrhythmia, PE, infection
    • Involve cardiology, pulmonology or other specialties
    • Continuous monitoring and tailored follow-up
new onset atrial fibrillation
  • Involve cardiology
  • Urgent/Emergent Cardioversion:
    • Active ischemia
    • Hypotension or shock
    • Severe heart failure
    • Pre-excitation (e.g., WPW + irregular wide QRS → high VF risk)
  • Rate Control (if not unstable)
    • Target HR < 110 bpm if asymptomatic with preserved EF OR < 80 bpm in HFrEF
    • First-line agents
      • Beta blockers
      • Non-DHP CCBs (e.g., diltiazem, verapamil)
      • Avoid CCBs in decompensated HF
    • IV route for rapid control
    • Consider Digoxin in HFrEF or if other agents are contraindicated
  • Rhythm Control if
    • New onset with a clear trigger, e.g., sepsis
    • Instability despite rate control
    • Amiodarone: 150–300 mg IV over 1 hour, then 10–50 mg/hour infusion over 24 hrs
    • BP-neutral; caution in hypotension
  • Anticoagulation
    • AF < 48 hours → can be considered pre-cardioversion
    • AF ≥ 48 hours or unknown duration
      • ≥ 4 weeks of anticoagulation before cardioversion
      • TEE can be used to rule out thrombus for earlier cardioversion
      • Continue anticoagulation ≥ 4 weeks post-cardioversion
    • Long-term anticoagulation

related · palpitations · ecg · hypotension · fever · chest pain

🔗 Related External Links

See also: MOC+ Volume 2: Cardiopulmonary — covers the tachyarrhythmias — SVT, AF, and or sinus tachycardia.

Studying for R1? The IM Rapid Review covers this in the same format — see the sample chapter.

Last reviewed · May 2026

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