PALPITATION

Co-assistant:
Dadik Ardhi Wijaya
Ricky Randana
Muhammad Bilal Saifulhaq

Lecturer:
dr. Ali Haedar, Sp.EM
 Background
Among the most common symptoms that prompt patients
to consult the GPs, cardiologists, or emergency
healthcare services.
Subjective perception about the abnormalities of hearts
activity, usually related with symptomatic arrhythmia.
It can be sudden or gradual onset, within seconds /
minutes / hours / days.
Irregularity of the heartbeat.
Sensation of thumping, pounding, or fluttering, either
intermitten or continuously.
 A disagreeable sensation of pulsation or
movement in the chest and/or adjacent areas
 Etiology
Cardiac arrhythmia (41%)
Psychosomatic disorders (31%)
Medications effects (6%)
Systemic causes (4%)
Structural heart diseases (3%)
Unspecified (16%)
 Pathophysiology
The contraction of the heart that are too rapid,
irregular, or particularly slow
Cardiac arrhythmias, mental disorder, systemic diseases, the
use of certain medications
Very intense contractions and anomalous
movements of the heart in chest
Structural heart diseases associated with increased stroke
volume
Anomalies in the subjective perception of the
heartbeat
Some psychosomatic disorders
 Heart Palpitation
Classification
Tachycardia, is a fast arrhythmia (HR > 100 bpm).
Fibrillation, is a very fast arrhythmia (HR > 300 bpm).
Premature Contraction is a single heartbeat that beats
earlier than normal, and it causes the sensation of forced
beat.
Abnormalities of the atrium, ventricle, or electric
transmission system (S-A Node or A-V Node) causing
palpitation-induced arrhythmia.
 The Classification and Clinical
Features of Palpitations
Type Subjective Heart Rate Onset dan Trigger Associating
Description termination Symptoms

Ekstrasystole skipping / Irregular, Sudden At Rest -

missing beat, overlapping with
sinking of the normal heart
heart beat

Tachycardia beating wings Reguler / Sudden Physical Activity Syncope, dyspneu,

on chest ireguler, fatigue, chest pain
sometimes beat
faster
Anxiety Disorder anxiety, agitation Reguler, little bit Gradual Stress, Anxiety Paresthetic on
faster hands and face,
dyspneu, atypical
chest pain

Pulsation Heart Beat Regular, normal Gradual Physical Activity Asthenia

(pounding) frequency
 Clinical Features of
Tachycardic
Palpitations
Arrhythmic Heart Rate Trigger Associating Vagal
Type Symptoms Manouvre
AVRT, Sudden Onset, Physical Poliuria Stop suddenly
AVNRT periodically activity,
increasing chaging of
body position
Atrial Irregular, Physical Poliuri HR decreased
Fibrillation variations of HR activity, temporarily
eating, alcohol
Atrial Regular (irregular - - HR decreased
tachycardia if there is any temporarily
or flutter variations in AV
conduction), HR
increases
Ventricular Regular with Physical Signs ad No effects
tachycardia increment of HR activity symptoms of
hemodynamic
disturbances
EKG Classifications of
Tachydysrhythmias
Narrow Complex Wide Complex
Regular Irregular Regular Irregular

Sinus tachycardia Atrial Monomorphic VT Polymorphic VT

Fibrillation
Supraventrikular Trial flutter with SVT with Any irregular,
tachycardia varying blocks abberancy narrow complex
tachycardia with
BBB or WPW
syndrome
Atrial flutter with Multifocal atrial Any regular,
1:1 or 2:1 tachycardia narrow complex
conduction tachycardia w/
bundle branch
block or Wolff-
Parkinson White
 Diagnostic Approach
The main purpose is determining whether the symptoms
caused by the arrhythmia threats life or not.
Evaluation of the patients started with history taking and
complete physical examination before doing the
additional examination.
 History Taking
Onset of the palpitation
Duration and frequency of palpitation
Aggraviating and Alleviating activities / factors
History of medications and diet
Family history of arrhythmia
 Signs and Symptoms
Chest fullness
Chest pain, shortness of breath, sweating, nausea,
vomiting
Dizziness or even syncope
Physical Examination
Vital signs
Pulsation examination
Jugular vein pressure
Heart auscultation
 Additional
Examination
Electrocardiography (ECG)
As a gold standard shows the cause of palpitation in 40%
patients
Echocardiography
 Management
Depends on the diagnosis causative therapy
Non-Pharmacologic 25% of SVT can be relieved with
valsava manuver / sinus carotis massage.
If VT/VF : defibrillation
Pharmacologic Adenosine, Verapamil, or Amiodarone
Tatalaksana pasien dengan palpitasi :
 Pharmacologic
Therapy
Adenosine Ultra Short Acting AV nodal blocker
Dosage: 6 mg IV rapid bolus at the proximal vein, followed
rapidly by 20 ml saline flow and arm elevation. Can be
repeated twice by the dosage of 12-30 mg IV
Verapamil (CCB)
As effective as adenosine
Disadvantages: Longer onset, more significant side effects
from decreasing of myocard contractility and peripheral
vasodilatation
 Pharmacologic
Therapy (contd)
Amiodarone is used if adenosine therapy fails and there
are signs of congestive heart failure.
Dosage: 150 mg IV in 10 minutes, can be repeated once
Diltiazem (CCB)
As effective as verapamil for narrow complex SVT
Dosage: 10-20 mg in 2 minutes. If it doesnt effective,
followed by the second bolus of 0,35mg/kg IV 15 minutes
later.
 Prognosis
Usually it isnt life threatening
Low mortality rate (1,6% annually)
High symptoms reccurency (up to 77%)
Disturbances in life quality (causing anxiety and high
frequency of ER administration)
Case Report
Identitas Pasien
Nama : Ny. L
Umur : 44 thn
Alamat : Tulungagung
Status Perkawinan : Menikah
N.Register : 1164xxxx
Agama : Islam
Tanggal MRS : 20-12-2016
Berat badan : 50 kg
 Anamnesa
Keluhan utama : Nyeri dada
Pasien datang dengan keluhan nyeri dada 1 minggu
yang lalu hilang timbul, keluhan memberat H-1 hari
smrs. pasien mengaku saat sedang melakukan
aktivitas biasa, disertai dengan pusing berputar dan
kadang-kadang sesak. Mual(+) muntah (-) dmam (-)
sinkop (-) Pasien kemudian dibawa ke RS dr iskak
 Riwayat Penyakit Dahulu
Pasien belum pernah mengalami keluhan yang sama
sebelumnya
DM (-), HT (-)
Riwayat Pengobatan
Pasien belum pernah berobat sebelumnya
Riwayat Alergi : (-)
Riwayat Penyakit Keluarga
Ibu pasien memiliki riwayat Htn dan DM
Riwayat Sosial
Pasien merupakan seorang Ibu Rumah Tangga dengan 2
orang anak
 Primary Survey
A : Paten, suara nafas tambahan snoring (-), gargling (-), stridor (-),
wheezing (-)

B : Ekspansi dada simetris, RR 20x/menit, reguler, dalam,

C : TD: 110/70 mmHg, Nadi : 189 x/menit, kuat, regular, akral

hangat, kulit lembab, turgor normal, CRT < 2 detik,

D : GCS 456 compos mentis, pupil bulat isokor 3mm / 3mm

E : Suhu aksila 36,0C

Triage P1
Initial Treatment
A : -

B : O2 10 lpm NRBM

C : Iv Ns 0,9 % loading 500 cc 20 tpm

D : -

E :-
Keadaan Umum: tampak sakit sedang
GCS 456 Berat Badan: 60kg
VAS 4/10 Tinggi badan : 158 cm
BP= 110/70 PR = 189 x/m RR = 20 x/m Tax : 36,0 0
C
mmHg
Head Anemic conjunctiva (-/-)
Icteric sclera (-/-)
Neck JVP Flat

Thorax Ictus invisible & palpable at ICS V 2 jari lateral MCL S,

Cor Heave (-), thrill (-)
RHM ~SL D, LHM ~ ics 2 jari lateral mcl sin ; S1 S2 reguler murmur (-)
Pulmo Symmetric Perkusi s v v Rh - Wh - -

s -
s v v -- - -

s
s v v -- - -

s
Abdomen Rounded , BS + N, soefl, liver span 8cm
Extremities edema Anemic - Cold acral Diaphoresis +
pitting - ++ +

- - -
- - ++ -
Lab
LABORATORY
Value
FINDING
(Normal) Lab Value (Normal)
Leucocyte 14.980 4.700 Natrium 138 136-145 mmol/L
11.300 /L
Haemoglobine 12,7 11,4 - 15,1 Kalium 4.3 3,5-5,0 mmol/L
g/dl
HCT 40,2 38 - 42% Chlorida 102 98-106 mmol/L
Trombocyte 523.000 142.000
424.000 /L
MCV 84.6 80-93 fl Ureum 8.9 20-40 mg/dL
MCH 26.7 27-31 pg Creatinine 0.72 <1,2 mg/dL
Eo/Bas/Neu/li 0,7/0.4/73. 0-4/0-1/51-
mf/Mon 8/17.8/7.8 67/25-33/2-5

Troponin I 0.11 <0.01

Pemeriksaan tambahan
Lab : DL, Ur/cr, BGA, SE, GDS, Tsh, T3/T4
EKG
Foto thorax AP
EKG
 Diagnosis Kerja
1. Vertigo perifer
2. Svt stable
Rencana Terapi
1. O2 10 lpm NRBM
2. Iv NaCl 0,9 % loading 500 cc maintenance 20cc/kgBB
3. Iv Omeprazole 2x40 mg
4. Iv Ondansetron 3x 4 mg
5. Dipenhidramin 1x20 mg
6. Betahistin 6 mg
7. Vagal manouvre ( jika 30 menit heart rate menetap dalam 30 mnt)
8. C/ Cardio Iv Amiodaron 150 mg (bolus pelan 15 mnt) -> maintenance
1 mg/menit habis dalam 6 jam .. Mrs ICCU

.Evaluasi
VS, keluhan subjektif, EKG. Tanda-tanda
unstable,
.KIE
terkait keadaan pasien, faktor resiko, terapi dan
prognosis
PEMBAHASAN
Teori Pasien

Dibandingkan dengan pasien -Pasien berusia 44

yang memiliki penyakit tahun
kardiovaskuler, PSVT tanpa
penyakit kardiovaskuler lebih
banyak pada usia muda (37 vs - HR: 205
69 th)
rate yang lebih cepat ( 186 vs
155 bpm) -Pasien wanita
Wanita memiliki risiko 2 kali
lipat dibanding pria -TD= 110/70, KU
Tanpa gangguan Cukup, GCS 456
hemodinamik, hanya
ditemukan takikardia.
Teori Pasien

Anamnesis: Gejala pada pasien:

Palpitasi (>96%) Nyeri dada
Pusing (75%) Pusing berputar
Sesak napas(47%)
Mual
Syncope (20%)
Nyeri dada (35%)
Fatigue (23%)
Diaphoresis (17%)
Nausea (13%)
CKD
Teori
dengan Overload
Pasien
Cairan
Rawat pasien di critical care area Pasien dirawat di area P1

Posisikan setengah duduk atau Semifowler position

upright position

Berikan high flow oxygen O2 NRBM 10 lpm

Monitoring: ECG, VS (5-10 VS, saturasi oksigen, GCS, keluhan

minutes), pulse oximetry subjektif sesak, produksi urin

Cek Lab DL, Ur/Cr, SE, BGA, DL, Ur/Cr, SE, BGA
cardiac enzyme
 Manajemen Terapi:

Teori Pasien

GTN 0.5 mg SL or Furosemid 120 mg iv

nitroderm patch 5-10 mg
atau 10-200 g/min i.v.

Morphine 2-5 mg i.v.

severe pulmonary oedema

Felodipine 2.5 mg p.o.

tekanan darah tinggi