Palpitations / tachyarrhythmia
A streamlined, differential-led presentation for rapid clinical review.
Twenty-second review
- Palpitations may reflect premature beats, supraventricular or ventricular tachyarrhythmia, atrial fibrillation, sinus tachycardia, anxiety, or an increased awareness of normal rhythm.
- Shock, ischemic chest pain, syncope, heart failure, sustained very rapid rhythm, or wide-complex tachycardia indicates instability.
- Keep sinus tachycardia from sepsis, pe, bleeding, or stimulant use in the differential; overlapping or concurrent illness remains possible.
- For palpitations / tachyarrhythmia, trends and combinations of findings are more informative than one isolated vital sign.
Compare the clinical patterns
The repeated material is grouped inside each possibility. Open only the condition you need.
Unstable tachyarrhythmiaTime-sensitive high-risk possibility
HPI
Clarify sudden onset; duration; current rhythm/rate.
Signs & symptoms
Poor perfusion, chest pain, syncope, or wide-complex findings.
Focused exam
Assess pulse rate, regularity, strength, skin perfusion, JVP, edema, and lung sounds; Compare current function and exercise tolerance with baseline.
Brief pathophysiology
Unstable tachyarrhythmia may cause palpitations / tachyarrhythmia through a time-sensitive process capable of rapid physiological deterioration.
What the trend may show
Rhythm, rate, symptoms, and perfusion determine urgency. A normal blood pressure does not exclude ischemia or a dangerous intermittent rhythm.
Heart rate (bpm)
Rate / rhythm abnormalCharacterize rate, regularity, onset, and ECG rhythm rather than assuming tachycardia.
Blood pressure (mmHg)
May be preserved or lowFalling pressure suggests reduced cardiac output or instability.
MAP (mmHg)
Trend perfusionInterpret with mentation, skin signs, and symptom trajectory.
Oxygen saturation (SpO₂)
Usually preservedAbnormal oxygenation suggests heart failure, ischemia, or another concurrent process.
Front-load in the triage report
- Unstable tachyarrhythmia: Poor perfusion, chest pain, syncope, or wide-complex findings.
- Sudden onset?
- Duration.
Ventricular rhythmTime-sensitive high-risk possibility
HPI
Clarify duration; current rhythm/rate; 12-lead.
Signs & symptoms
Poor perfusion, chest pain, syncope, or wide-complex findings.
Focused exam
Compare current function and exercise tolerance with baseline; Compare monitored rhythm with pulse, obtain 12-lead, and assess perfusion, heart failure signs, stimulant use, thyroid symptoms, and bleeding.
Brief pathophysiology
Ventricular rhythm may cause palpitations / tachyarrhythmia through a time-sensitive process capable of rapid physiological deterioration.
What the trend may show
Rhythm, rate, symptoms, and perfusion determine urgency. A normal blood pressure does not exclude ischemia or a dangerous intermittent rhythm.
Heart rate (bpm)
Rate / rhythm abnormalCharacterize rate, regularity, onset, and ECG rhythm rather than assuming tachycardia.
Blood pressure (mmHg)
May be preserved or lowFalling pressure suggests reduced cardiac output or instability.
MAP (mmHg)
Trend perfusionInterpret with mentation, skin signs, and symptom trajectory.
Oxygen saturation (SpO₂)
Usually preservedAbnormal oxygenation suggests heart failure, ischemia, or another concurrent process.
Front-load in the triage report
- Ventricular rhythm: Poor perfusion, chest pain, syncope, or wide-complex findings.
- Duration.
- Current rhythm/rate.
Benign ectopyCommon presentation pattern
HPI
Clarify sudden onset; duration; current rhythm/rate.
Signs & symptoms
Intermittent symptoms with preserved perfusion and compatible ECG may occur.
Focused exam
Assess pulse rate, regularity, strength, skin perfusion, JVP, edema, and lung sounds; Compare current function and exercise tolerance with baseline.
Brief pathophysiology
Benign ectopy may explain the presenting symptoms through a common clinical mechanism, while serial assessment checks for complications or an alternate cause.
What the trend may show
Rhythm, rate, symptoms, and perfusion determine urgency. A normal blood pressure does not exclude ischemia or a dangerous intermittent rhythm.
Heart rate (bpm)
Rate / rhythm abnormalCharacterize rate, regularity, onset, and ECG rhythm rather than assuming tachycardia.
Blood pressure (mmHg)
May be preserved or lowFalling pressure suggests reduced cardiac output or instability.
MAP (mmHg)
Trend perfusionInterpret with mentation, skin signs, and symptom trajectory.
Oxygen saturation (SpO₂)
Usually preservedAbnormal oxygenation suggests heart failure, ischemia, or another concurrent process.
Front-load in the triage report
- Intermittent symptoms with preserved perfusion and compatible ECG may occur.
- Sudden onset?
- Duration.
Supraventricular rhythmCommon presentation pattern
HPI
Clarify duration; current rhythm/rate; 12-lead.
Signs & symptoms
Intermittent symptoms with preserved perfusion and compatible ECG may occur.
Focused exam
Compare current function and exercise tolerance with baseline; Compare monitored rhythm with pulse, obtain 12-lead, and assess perfusion, heart failure signs, stimulant use, thyroid symptoms, and bleeding.
Brief pathophysiology
Supraventricular rhythm may explain the presenting symptoms through a common clinical mechanism, while serial assessment checks for complications or an alternate cause.
What the trend may show
Rhythm, rate, symptoms, and perfusion determine urgency. A normal blood pressure does not exclude ischemia or a dangerous intermittent rhythm.
Heart rate (bpm)
Rate / rhythm abnormalCharacterize rate, regularity, onset, and ECG rhythm rather than assuming tachycardia.
Blood pressure (mmHg)
May be preserved or lowFalling pressure suggests reduced cardiac output or instability.
MAP (mmHg)
Trend perfusionInterpret with mentation, skin signs, and symptom trajectory.
Oxygen saturation (SpO₂)
Usually preservedAbnormal oxygenation suggests heart failure, ischemia, or another concurrent process.
Front-load in the triage report
- Intermittent symptoms with preserved perfusion and compatible ECG may occur.
- Duration.
- Current rhythm/rate.
Sinus tachycardia from sepsisImportant alternative presentation
HPI
Clarify sudden onset; duration; current rhythm/rate.
Signs & symptoms
The rhythm may be a response rather than the primary disease.
Focused exam
Assess pulse rate, regularity, strength, skin perfusion, JVP, edema, and lung sounds; Compare current function and exercise tolerance with baseline.
Brief pathophysiology
Sinus tachycardia from sepsis can resemble palpitations / tachyarrhythmia through overlapping symptoms or referred physiology despite a different primary mechanism.
What the trend may show
No single vital sign diagnoses sepsis. New tachypnea, abnormal temperature, tachycardia, or falling pressure—especially with altered mentation or poor perfusion—supports organ dysfunction and urgency.
Respiratory rate (breaths/min)
May rise earlyTachypnea is included in NEWS2 and can precede overt hypotension.
Temperature (°C)
High or lowAbsence of fever does not exclude sepsis; hypothermia is concerning.
Heart rate (bpm)
Often risesTachycardia is common but may be blunted by age or medication.
Blood pressure (mmHg)
May fallRelative hypotension and trend matter; profound hypotension can be late.
Front-load in the triage report
- The rhythm may be a response rather than the primary disease.
- Sudden onset?
- Duration.
PEImportant alternative presentation
HPI
Clarify duration; current rhythm/rate; 12-lead.
Signs & symptoms
The rhythm may be a response rather than the primary disease.
Focused exam
Compare current function and exercise tolerance with baseline; Compare monitored rhythm with pulse, obtain 12-lead, and assess perfusion, heart failure signs, stimulant use, thyroid symptoms, and bleeding.
Brief pathophysiology
PE can resemble palpitations / tachyarrhythmia through overlapping symptoms or referred physiology despite a different primary mechanism.
What the trend may show
Pulmonary embolism may have normal observations. Tachycardia, tachypnea, or hypoxemia increase concern; hypotension identifies hemodynamic compromise rather than being required for diagnosis.
Heart rate (bpm)
May riseTachycardia is common but neither sensitive nor specific.
Respiratory rate (breaths/min)
May riseTachypnea may be an early sign of increased ventilatory demand.
Oxygen saturation (SpO₂)
May fallHypoxemia may occur, but a normal saturation does not exclude PE.
Blood pressure (mmHg)
Often preservedHypotension suggests high-risk PE with obstructive shock.
Front-load in the triage report
- The rhythm may be a response rather than the primary disease.
- Duration.
- Current rhythm/rate.
BleedingImportant alternative presentation
HPI
Clarify current rhythm/rate; 12-lead; regular vs irregular.
Signs & symptoms
The rhythm may be a response rather than the primary disease.
Focused exam
Compare current function and exercise tolerance with baseline; Compare monitored rhythm with pulse, obtain 12-lead, and assess perfusion, heart failure signs, stimulant use, thyroid symptoms, and bleeding.
Brief pathophysiology
Bleeding can resemble palpitations / tachyarrhythmia through overlapping symptoms or referred physiology despite a different primary mechanism.
What the trend may show
Rhythm, rate, symptoms, and perfusion determine urgency. A normal blood pressure does not exclude ischemia or a dangerous intermittent rhythm.
Heart rate (bpm)
Rate / rhythm abnormalCharacterize rate, regularity, onset, and ECG rhythm rather than assuming tachycardia.
Blood pressure (mmHg)
May be preserved or lowFalling pressure suggests reduced cardiac output or instability.
MAP (mmHg)
Trend perfusionInterpret with mentation, skin signs, and symptom trajectory.
Oxygen saturation (SpO₂)
Usually preservedAbnormal oxygenation suggests heart failure, ischemia, or another concurrent process.
Front-load in the triage report
- The rhythm may be a response rather than the primary disease.
- Current rhythm/rate.
- 12-lead.
Stimulant useImportant alternative presentation
HPI
Clarify 12-lead; regular vs irregular; chest pain, dyspnea, syncope or dizziness.
Signs & symptoms
The rhythm may be a response rather than the primary disease.
Focused exam
Compare current function and exercise tolerance with baseline; Compare monitored rhythm with pulse, obtain 12-lead, and assess perfusion, heart failure signs, stimulant use, thyroid symptoms, and bleeding.
Brief pathophysiology
Stimulant use can resemble palpitations / tachyarrhythmia through overlapping symptoms or referred physiology despite a different primary mechanism.
What the trend may show
Autonomic excess can produce tachycardia, hypertension, hyperthermia, and tachypnea. Marked temperature elevation or deterioration is a time-critical finding.
Heart rate (bpm)
Often elevatedTachycardia is common with sympathetic activation.
Blood pressure (mmHg)
Often elevatedHypertension is common, though collapse or mixed toxicity can lower pressure.
Temperature (°C)
May rise dangerouslyHyperthermia signals severe toxicity and requires urgent management.
Respiratory rate (breaths/min)
Often elevatedTachypnea may reflect agitation, hyperthermia, or metabolic acidosis.
Front-load in the triage report
- The rhythm may be a response rather than the primary disease.
- 12-lead.
- Regular vs irregular.
Findings that should escalate concern
- Shock, ischemic chest pain, syncope, heart failure, sustained very rapid rhythm, or wide-complex tachycardia indicates instability.
- Unstable tachyarrhythmia or ventricular rhythm: Poor perfusion, chest pain, syncope, or wide-complex findings.
Medication recognition
Continue the clinical pathway
Clinical and academic sources
Curated clinical guidance and peer-reviewed evidence supporting this presentation. Current BCEHS guidance, medical direction, and local policy remain authoritative for practice.
BCEHS Handbook — specific CPGs
- C03: Narrow Complex TachycardiaBC Emergency Health Services Handbook
Official BCEHS clinical practice guidance for narrow complex tachycardia.
- C04: Wide Complex TachycardiaBC Emergency Health Services Handbook
Official BCEHS clinical practice guidance for wide complex tachycardia.
Supporting clinical and academic evidence
- Guideline for the Management of Patients With Acute Coronary SyndromesACC/AHA/ACEP/NAEMSP/SCAI
2025 evidence-based acute coronary syndrome recognition and management guidance.
- CEDIS Presenting Complaint List updateCanadian Association of Emergency Physicians
Presenting-complaint terminology and categorization context. It does not establish a prehospital “top 100” ranking.
- Tachyarrhythmias and Bradyarrhythmias: Differential Diagnosis and Initial ManagementMedical Clinics of North America · 2017
Rhythm-based differential diagnosis and initial assessment of symptomatic tachyarrhythmias and bradyarrhythmias.