Palpitations are defined as a conscious awareness of one’s heartbeat. They are usually perceived over the precordium, throat, or neck and may be described as pounding, jumping, fluttering, flopping, or “skipping.” They may be regular or irregular, fast or slow, and paroxysmal or sustained.

Although commonly benign, palpitations can result from cardiac or metabolic disorders, medications, or stimulants (e.g., caffeine, tobacco). They may also occur with emotional or physical stress, or in patients with newly implanted prosthetic valves whose clicking sounds heighten awareness of the heartbeat.

Emergency interventions

• Assess for dizziness, syncope, dyspnea, chest pain, or diaphoresis.

• Inspect for pale, cool, clammy skin.

• Check vital signs: pulse (rate, rhythm, regularity), blood pressure, oxygen saturation.

• If hypotension, irregular pulse, or altered consciousness is present, suspect a cardiac arrhythmia.

• Initiate:

  • Continuous cardiac monitoring / 12-lead ECG.

  • Oxygen via nasal cannula or mask.

  • Establish an I.V. line; prepare to administer appropriate antiarrhythmics.

  • Keep defibrillation/cardioversion equipment readily available.

History and Physical Examination

History

• Characterize palpitations: onset, duration, frequency, precipitating or relieving factors, relation to exertion, posture, or emotional stress.

• Ask the patient to tap the rhythm on a hard surface (irregular = premature beats; abrupt fast = paroxysmal tachycardia).

• Explore:

  • Cardiovascular/pulmonary disorders (e.g., arrhythmias, heart failure, valvular disease).

  • Endocrine/metabolic disorders (e.g., thyrotoxicosis, hypoglycemia).

  • Personal/family history of arrhythmias or sudden cardiac death.

  • Medication and substance use (digoxin, beta-agonists, cocaine, caffeine, alcohol, nicotine).

  • Associated symptoms: weakness, fatigue, chest pain, shortness of breath, anxiety.

Physical examination

• Obtain vital signs, noting orthostatic changes.

• Inspect skin for pallor, diaphoresis, cyanosis.

• Auscultate heart for murmurs, gallops, clicks, or abnormal heart sounds.

• Evaluate lung fields for crackles or wheezes.

• Assess thyroid size, jugular venous distention, and peripheral edema.

Medical causes

Special considerations

• Prepare for diagnostic evaluation:

  • 12-lead ECG, Holter/event monitoring.

  • Serum electrolytes, thyroid function tests, glucose, calcium, magnesium.

  • Echocardiography if structural heart disease suspected.

• Even mild palpitations may cause severe anxiety—provide reassurance in a quiet environment.

• Address lifestyle triggers: caffeine, tobacco, alcohol, stress, and stimulant drugs.

Patient counseling

• Explain diagnostic procedures and their purpose.

• Teach stress-reduction strategies: controlled breathing, adequate sleep, avoiding stimulants.

• Educate about warning signs that require prompt evaluation:

  • Syncope or presyncope

  • Chest pain or pressure

  • Severe shortness of breath

  • New or worsening edema

Pediatric pointers

• Common causes: fever, congenital heart defects (PDA, septal defects), arrhythmias.

• Children may be unable to describe palpitations; focus on:

  • Heart rate/rhythm monitoring

  • Physical examination

  • ECG and laboratory tests

• Reassure parents and teach them to observe for syncope, fatigue, or poor feeding.

References

• Berkowitz CD. Berkowitz’s Pediatrics: A Primary Care Approach. 4th ed. USA: American Academy of Pediatrics; 2012.

• Buttaro TM, Tybulski J, Bailey PP, Sandberg-Cook J. Primary Care: A Collaborative Practice. St. Louis, MO: Mosby Elsevier; 2008.

• Colyar MR. Well-Child Assessment for Primary Care Providers. Philadelphia, PA: F.A. Davis; 2003.

• Lehne RA. Pharmacology for Nursing Care. 7th ed. St. Louis, MO: Saunders Elsevier; 2010.

• McCance KL, Huether SE, Brashers VL, Rote NS. Pathophysiology: The Biologic Basis for Disease in Adults and Children. Maryland Heights, MO: Mosby Elsevier; 2010.

• Sommers MS, Brunner LS. Pocket Diseases. Philadelphia, PA: F.A. Davis; 2012.