3-111
Assessment:
Differential Diagnosis
Tachycardia - normal if demand for cardiac output is high as in anemia, fever, exercise, anxiety, dehydration,
hypoxia. Over 150 at rest is abnormal unless hypovolemic.
Bradycardia - normal athletic adults have HR as low as 40 with skips due to second degree AV block.
PVCs - wide (>3 little boxes) QRS complexes that occur out of synchronization with the other beats.
PACs - narrow (<3 little boxes) QRS complexes that occur out of synchronization with the other beats.
Heart Block - dropped or missing QRS where one would have been expected
PSVT - narrow QRS occurring at a rate >150
Atrial Fibrillation - QRS complexes occurring irregularly irregular without a P wave in front of them.
Plan:
Treatment
- REASSURANCE. Make the patient calm.
- Prevention: Remove causes (caffeine, sleep deprivation, OTC medications)
- Valsalva maneuver: Bear down like having a bowel movement; this will stop or slow all supraventricular
tachycardias, at least momentarily. - Carotid massage: After auscultation for bruits, massage the right carotid for 15 seconds
- Diving reflex: Place the member’s face in a basin of cold or ice water
- Medications: Diazepam 5 mg po. Propranolol 20-40 mg po qid (hyperthyroidism may require up to 480
mg/day). Verapamil 40-80 mg po qid if asthma precludes use of propranolol. Do not use in wide complex
tachycardias. - Treat atrial fibrillation (AF) with propranolol or verapamil in increasing doses until the heart rate is under
100 during a slow jog in place. AF is not a heart attack, can be controlled in the field, and does not
require evacuation UNLESS it is caused by a heart attack or pulmonary embolism. - Treat acute coronary cause as in the Symptom: Chest Pain section.
Patient Education
General: Palpitations are ALMOST always not life threatening. The patient is not having a heart attack.
Activity: If no syncope or near syncope symptoms, then no restriction is indicated. When the symptoms of
rapid heart beating come on, the member should sit down and bear down.
Diet: Avoid caffeine
Medications: Propranolol may cause tiredness and verapamil may cause constipation.
Prevention: Avoid those medications and foods that cause symptoms. Get plenty of rest.
No improvement/Deterioration: If symptoms persist, worsen, or are associated with syncope or pre-
syncope return to the clinic.
Follow-up Actions
Return evaluation: Increase dose of propranolol up to 360 mg total per day. If symptoms continue, remove
the member from the field.
Evacuation/Consultation Criteria: Evacuate if unable to perform duties, if symptoms are not controlled
or underlying heart disease is suspected. The presence of stable PVCs, PACs, PSVT, or AF should not be
the sole cause to remove the member from the field while performing critical mission executions. Consult
cardiology or internal medicine as needed.
NOTE: See service specific Aviation and Diving Medicine guidelines for operators performing special duty.