Palpitations are a common symptom experienced by individuals of all ages and are frequently encountered in the emergency department (ED). They are characterized by the sensation of an abnormally rapid, irregular, or forceful heartbeat. As a junior doctor in emergency medicine, it is important to understand the potential causes, assessment, and management strategies for palpitations.
Understanding Palpitations
Palpitations can feel like the heart is:
Racing or beating too fast
Thumping or pounding
Fluttering
Skipping beats
These sensations may be felt in the chest, throat, or neck and can occur during activity or at rest[1][3].
Common Causes of Palpitations
Cardiac Causes
Arrhythmias: Such as atrial fibrillation, atrial flutter, ventricular tachycardia, and premature ventricular contractions[2].
Structural Heart Disease: Including cardiomyopathy and valvular heart disease[1][4].
Congenital Conditions: Such as Wolff-Parkinson-White syndrome and long QT syndrome[1].
Non-Cardiac Causes
Psychiatric Conditions: Anxiety, panic attacks, and stress can trigger palpitations[3][4].
Metabolic Disorders: Hyperthyroidism, hypoglycemia, and electrolyte imbalances (e.g., hypokalemia)[2].
Substance Use: Caffeine, nicotine, alcohol, recreational drugs (e.g., cocaine, amphetamines), and certain medications[3][4].
Other Factors
Hormonal Changes: Associated with menstruation, pregnancy, or menopause[4].
Exercise or Physical Activity: Can increase heart rate and lead to palpitations[3].
Initial Assessment and Management
History Taking
A detailed history is crucial to guide further evaluation:
Onset, duration, and frequency of palpitations
Associated symptoms such as chest pain, dizziness, shortness of breath, or syncope
Triggers or relieving factors
Past medical history including heart disease or arrhythmias
Medication use and substance intake
Physical Examination
The physical examination should focus on identifying signs that may indicate specific causes:
Cardiovascular examination: Assess heart rate and rhythm.
Thyroid examination: Check for signs of hyperthyroidism.
General examination: Evaluate for signs of systemic illness.
Diagnostic Workup
Depending on clinical suspicion from history and examination, the following tests may be considered:
Electrocardiogram (ECG): To assess for arrhythmias or other cardiac abnormalities[6].
Holter Monitoring: For continuous ECG monitoring over 24 hours if palpitations are intermittent[6].
Blood Tests: Including thyroid function tests and electrolyte panels.
Management Strategies
Management of palpitations in the ED focuses on addressing both symptom relief and underlying causes:
Symptomatic Treatment:
Reassurance for benign cases with no underlying pathology.
Vagal maneuvers (e.g., Valsalva maneuver) for certain types of supraventricular tachycardia.
Specific Interventions:
Antiarrhythmic medications for confirmed arrhythmias.
Beta-blockers may be used to control heart rate in some cases.
Monitoring and Follow-up:
Referral to cardiology for further evaluation if needed.
Continuous monitoring if there is suspicion of a serious underlying condition.
Challenges and Considerations
Palpitations can be challenging due to their broad differential diagnosis. It is crucial to identify red flags that suggest serious underlying conditions requiring urgent intervention. These include severe chest pain, syncope, severe shortness of breath, or a history of significant heart disease.
By taking a systematic approach to the assessment and management of palpitations, you can effectively address this common symptom in the emergency setting while ensuring appropriate follow-up care.
Citations: [1] https://www.healthdirect.gov.au/heart-palpitations [2] https://www.ncbi.nlm.nih.gov/books/NBK436016/ [3] https://www.mayoclinic.org/diseases-conditions/heart-palpitations/symptoms-causes/syc-20373196 [4] https://www.hopkinsmedicine.org/health/conditions-and-diseases/palpitations [5] https://scholar.harvard.edu/files/barkoudah/files/managementofpalpitations.pdf [6] https://www.mayoclinic.org/diseases-conditions/heart-palpitations/diagnosis-treatment/drc-20373201
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