Sandbox2

❑ Hemodynamic instability
❑ Hypotension
❑ Cold extremities
❑ Peripheral cyanosis
❑ Mottling
❑ Altered mental status

Identify cardinal symptoms and signs that increase the pre-test probability of palpitations

Symprtoms:
❑ Flip-flopping of the chest
❑ Rapid fluttering of the chest
❑ Pounding in the neck
❑ Pulsation palpitations
Signs:
❑ Increased heart rate with regular or irregular rhythm
❑ Cardiological findings suggestive of a cardiological disease

❑ Murmurs

❑ S3 sound

❑ Muffled heart sounds

❑ Displaced apex beat

Does the patient have any of the followign findings that require urgent management?

❑ Palpitations asociated with syncope (suggestive of VT of structural heart disease) ❑ Chest discomfort suggestive of ischemia
❑ Decompensated heart failure

❑ Consider electrical cardioversion

Yes

No

Does the patient have any of the following findings suggesting of hemodynamic instability?

Continue with the complete duagnostic apporoach shown below

Yes

No

Stabilize the patient

❑ Assess circulation, secure airway and breathing
❑ Secure IV line
❑ Offer oxygen
❑ Cardiac monitor to identify rhythm

❑ Monitor blood pressure and oximetry

Order and EKG immediately

Does the patient has any EKG findings suggestive of an arrhythmia?

Yes

No

Narrow complex tachycardia
Wide complex tachycardia
Bradycardia
WPW

Does the patient have any EKG findings suggestive of myocardial ischemia or pericarditis?

STEMI
❑ ST elevation in at least 2 contiguous leads of 2 mm (0.2 mV) in men or 1.5 mm (0.15 mV) in women in leads V2–V3 and/or of 1 mm (0.1mV) in other contiguous chest leads or the limb leads
❑ ST depression in at least two precordial leads V1-V4 (suggestive of posterior MI)
❑ ST depression in several leads plus ST elevation in lead aVR (suggestive of occlusion of the left main or proximal LAD artery)
❑ New LBBB