Initial Approach to Breathlessness with Palpitations
Begin with immediate assessment of hemodynamic stability by simultaneously evaluating heart rate and respiratory status within 10 seconds, while preparing for potential cardiovascular collapse. 1
Immediate Assessment (First 60 Seconds)
Rapidly determine if the patient is hemodynamically stable or unstable by assessing three vital characteristics simultaneously:
- Heart rate: Determine if >150 beats/min (more likely primary arrhythmia) or <150 beats/min (more likely secondary to underlying condition) 1
- Respiratory status: Look for signs of increased work of breathing including tachypnea, intercostal retractions, suprasternal retractions, or paradoxical abdominal breathing 1
- Oxyhemoglobin saturation: Measure via pulse oximetry immediately, as hypoxemia is a common cause of both breathlessness and tachycardia 1
Check for signs of instability that indicate rate-related cardiovascular compromise:
- Acute altered mental status 1
- Ischemic chest discomfort 1
- Acute heart failure 1
- Hypotension or other signs of shock 1
Initial Interventions Based on Stability
If Unstable (Any Sign of Rate-Related Compromise)
Proceed immediately to synchronized cardioversion without delay if the patient demonstrates cardiovascular compromise suspected to be due to the tachyarrhythmia. 1
- Attach cardiac monitor and establish IV access while preparing for cardioversion 1
- For regular narrow-complex SVT in non-hypotensive patients, adenosine may be administered while preparing for cardioversion (though this should not delay definitive treatment) 1
If Stable
Provide supplementary oxygen if oxyhemoglobin saturation is <94% or if signs of heart failure, shock, or breathlessness are present. 1
Attach continuous cardiac monitoring, evaluate blood pressure, and establish IV access. 1
Obtain a 12-lead ECG to define the rhythm, but do not delay treatment if the patient becomes unstable. 1
Determine Underlying Etiology
Distinguish between primary arrhythmia versus secondary tachycardia:
- Heart rate <150 beats/min: More likely that tachycardia is secondary to an underlying condition (fever, anemia, hypotension, dehydration) rather than the cause of instability, especially without ventricular dysfunction 1
- Heart rate >150 beats/min: More likely attributable to a primary arrhythmia requiring specific treatment 1
For sinus tachycardia (most common cause): Direct therapy toward identification and treatment of the underlying cause rather than rate control 1
Critical Pitfalls to Avoid
Do not attempt to "normalize" heart rate in compensatory tachycardia where cardiac function is poor, as cardiac output may be dependent on the rapid rate. 1
Do not delay cardioversion in unstable patients to obtain a 12-lead ECG or establish IV access if signs of cardiovascular compromise are present. 1
Recognize that breathlessness with palpitations may represent acute coronary syndrome—assess for ischemic chest discomfort and obtain cardiac biomarkers if ACS is suspected. 1
Ensure pulse oximetry is applied early, as it provides continuous assessment without interrupting other resuscitation measures, though it may take 1-2 minutes to function and may not work in states of very poor perfusion. 1