Sinus tachycardia: Difference between revisions
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===Causes=== | ===Causes=== | ||
*Emotional or psychiatric causes | *Emotional or psychiatric causes | ||
**Pain, anger, or anxiety | **Pain, anger, or [[anxiety]] | ||
*Response to [[fever]] (about 10 bpm per degree C > 37.0) | *Response to [[fever]] (about 10 bpm per degree C > 37.0) | ||
* [[SIRS]] (from infection or other causes) | * [[SIRS]] (from infection or other causes) | ||
*Dehydration/ | *[[Dehydration]]/[[hypovolemia]] | ||
*[[Anemia]] | *[[Anemia]] | ||
*Drug/[[alcohol intoxication]] (particularly sympathomimetic or anticholinergic drugs, but may also be seen in aspirin, theophylline, or other ingestions) | *Drug/[[alcohol intoxication]] (particularly [[sympathomimetic]] or [[anticholinergic drugs]], but may also be seen in [[salicylate toxicity|aspirin]], [[theophylline toxicity|theophylline]], or other ingestions) | ||
*Drug/[[alcohol withdrawal]] | *Drug/[[alcohol withdrawal]] | ||
*[[Anion gap acidosis]] | *[[Anion gap acidosis]] | ||
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*[[Cardiac tamponade]] | *[[Cardiac tamponade]] | ||
*[[Myocardial contusion]] | *[[Myocardial contusion]] | ||
*[[ | *Cardiac [[valvular disease]] | ||
*Hyper or [[hypoglycemia]] | *[[Hyperglycemia|Hyper]] or [[hypoglycemia]] | ||
*[[Myocardial infarction]] | *[[Myocardial infarction]] | ||
*[[Pheochromocytoma]] | *[[Pheochromocytoma]] | ||
==Clinical Features== | ==Clinical Features== | ||
*[[Palpitations]] | *Tachycardia | ||
*+/- [[Palpitations]] | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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**CBC | **CBC | ||
**BMP | **BMP | ||
** | **[[Utox]] | ||
**Urine pregnancy | **Urine pregnancy | ||
*Consider: | *Consider: | ||
**Empiric treatment for anxiety or pain (e.g. [[benzodiazepine]] or [[NSAID]]) | **Empiric treatment for [[anxiety]] or [[analgesia|pain]] (e.g. [[benzodiazepine]] or [[NSAID]]) | ||
**[[Urinalysis]] | **[[Urinalysis]] | ||
**TSH | **TSH | ||
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==Management== | ==Management== | ||
*Tailored to specific cause of sinus tachycardia: | *Tailored to specific cause of sinus tachycardia: | ||
**Fluids for dehydration | **[[IVF|Fluids]] for dehydration | ||
**Blood for hemorrhage | **[[pRBCs|Blood]] for hemorrhage | ||
** | **[[Anticoagulation]]/[[thrombolytics]] for [[PE]] | ||
**Antibiotics and fluids for sepsis | **[[Sepsis antibiotics|Antibiotics]] and fluids for [[sepsis]] | ||
**Benzodiazepines for alcohol withdrawal | **[[Benzodiazepines]] for [[alcohol withdrawal]] | ||
**Supportive care for intoxication | **Supportive care for intoxication | ||
*If no cause identified, treat with caution | *If no cause identified, treat with caution | ||
**Beta blockers or other | **[[Beta blockers]] or other [[antiarrhythmics]] are '''not''' appropriate for unexplained sinus tachycardia as patient may require elevated heart rate to maintain appropriate cardiac output depending on underlying cause | ||
**May consider discharge with strict return precautions if no clear cause identified and no serious pathology suspected after careful work-up | **May consider discharge with strict return precautions if no clear cause identified and no serious pathology suspected after careful work-up | ||
***Ensure close follow-up and strict return precautions | ***Ensure close follow-up and strict return precautions |
Revision as of 16:17, 26 September 2019
Background
- Sinus rhythm at a rate above the upper limit of normal
- In adults, usually >100 bpm
- In pediatric patients it varies by age until age 8 or 9 (see pediatric vital signs)
- Usually seen as a secondary response to a primary medical condition
Causes
- Emotional or psychiatric causes
- Pain, anger, or anxiety
- Response to fever (about 10 bpm per degree C > 37.0)
- SIRS (from infection or other causes)
- Dehydration/hypovolemia
- Anemia
- Drug/alcohol intoxication (particularly sympathomimetic or anticholinergic drugs, but may also be seen in aspirin, theophylline, or other ingestions)
- Drug/alcohol withdrawal
- Anion gap acidosis
- Hyperthyroidism
- PE
- CHF
- Cardiac tamponade
- Myocardial contusion
- Cardiac valvular disease
- Hyper or hypoglycemia
- Myocardial infarction
- Pheochromocytoma
Clinical Features
- Tachycardia
- +/- Palpitations
Differential Diagnosis
Narrow-complex tachycardia
- Regular
- AV Node Independent
- Sinus tachycardia
- Atrial tachycardia (uni-focal or multi-focal)
- Atrial fibrillation
- Atrial flutter
- Idiopathic fascicular left ventricular tachycardia
- AV Node Dependent
- AV Node Independent
- Irregular
- Multifocal atrial tachycardia (MAT)
- Sinus tachycardia with frequent PACs, PJCs, PVCs
- Atrial fibrillation
- Atrial flutter with variable conduction
- Digoxin Toxicity
Wide-complex tachycardia
Assume any wide-complex tachycardia is ventricular tachycardia until proven otherwise (it is safer to incorrectly assume a ventricular dysrhythmia than supraventricular tachycardia with abberancy)
- Regular
- Monomorphic ventricular tachycardia
- PSVT with aberrant conduction:
- PSVT with bundle branch block^
- PSVT with accessory pathway
- Atrial flutter with bundle branch block^
- Sinus tachycardia with bundle branch block^
- Accelerated idioventricular rhythm (consider if less than or ~120 bpm)
- Metabolic
- Irregular
- Atrial fibrillation/atrial flutter with variable AV conduction AND bundle branch block^
- Atrial fibrillation/atrial flutter with variable AV conduction AND accessory pathway (e.g. WPW)
- Atrial fibrillation + hyperkalemia
- Polymorphic ventricular tachycardia
^Fixed or rate-related
Evaluation
Workup
- ECG
- History and physical exam
- Look for intoxication/withdrawal, infection, dehydration, bleeding, or a psychiatric/emotional state
- Consider orthostatic vital signs
- If history and physical are unable to explain the tachycardia, limited labs and imaging studies may be indicated:
- CBC
- BMP
- Utox
- Urine pregnancy
- Consider:
- Empiric treatment for anxiety or pain (e.g. benzodiazepine or NSAID)
- Urinalysis
- TSH
- Troponin
- CXR
- Consider workup for PE (e.g. D-dimer or CTA)
Diagnosis
- Based on ECG
- Look for regular rate and presence of p-waves to support diagnosis of sinus tachycardia
Management
- Tailored to specific cause of sinus tachycardia:
- Fluids for dehydration
- Blood for hemorrhage
- Anticoagulation/thrombolytics for PE
- Antibiotics and fluids for sepsis
- Benzodiazepines for alcohol withdrawal
- Supportive care for intoxication
- If no cause identified, treat with caution
- Beta blockers or other antiarrhythmics are not appropriate for unexplained sinus tachycardia as patient may require elevated heart rate to maintain appropriate cardiac output depending on underlying cause
- May consider discharge with strict return precautions if no clear cause identified and no serious pathology suspected after careful work-up
- Ensure close follow-up and strict return precautions
Disposition
- Depends on cause of tachycardia:
- Home for pain, fever, or anxiety resolving with appropriate treatment
- Certain withdrawal or intoxication syndromes may require ED observation or admission
- ICU for severe sepsis
- OR for life-threatening hemorrhage