Tachycardia 🫀
Ward bleep guide for a fast heart rate or palpitations: 12-lead ECG fork, sinus tachycardia and reversible causes, RCUK tachyarrhythmia algorithm, and when to escalate.
Educational adult tachyarrhythmia algorithm
RCUK 2025 guidelines (V3 March 2026). For peri-arrest tachyarrhythmia of abnormal origin only. Always follow local resuscitation policy in an emergency.
1. Initial actions
- ABCDE assessment
- Monitor ECG, BP, SpO₂; record 12-lead ECG
- Give oxygen if SpO₂ <94%
- Obtain IV access and identify and treat reversible causes
2. Rhythm on 12-lead ECG
Algorithm branch
Select options above- Confirm rhythm on 12-lead ECG
Source: RCUK Adult Tachyarrhythmia Algorithm V3 March 2026 (PDF)
First steps (before you branch)
- Get a 12-lead ECG before you treat the rate. That separates sinus tachycardia from SVT, AF, and VT.
- Palpitations with a normal rate or sinus rhythm on ECG: reassure if well, treat anxiety or a clear cause, document, and step up obs if needed. The sections below focus on tachycardia on ECG or monitor.
- Broad-complex tachycardia or suspected VT: crash call the resuscitation team. Do not manage this alone.
- New SVT or new fast AF on ECG: get a senior to the bedside before you start rate or rhythm treatment.
- RCUK life-threatening features with a tachyarrhythmia: shock; syncope with severe or ongoing hypotension; myocardial ischaemia; severe heart failure with pulmonary oedema; or immediately post-ROSC. Call for help and use the RCUK algorithm at the top of this page.
- Do not give antiarrhythmics or synchronised cardioversion for sinus tachycardia. Treat the driver instead.
Sinus tachycardia: treat the driver
- Sinus tachycardia is a response, not a primary rhythm problem. The RCUK tachyarrhythmia algorithm does not apply.
- Typical drivers: pain, distress, fever or sepsis, blood loss or dehydration, hypoxia, PE, ACS, electrolyte disturbance, and drugs or caffeine.
- Do not try to normalise the heart rate with antiarrhythmic medication or synchronised cardioversion.
📞 What to ask / orders to make
- Current NEWS, AVPU, and whether the patient looks unwell.
- Manual pulse: rate, and whether it is regular or irregular. Do not rely on the monitor number alone.
- Blood pressure. Chest pain, breathlessness, dizziness, or collapse?
- Has a 12-lead ECG been done? If not, request one now.
- Fever, obvious bleeding, uncontrolled pain, or a missed dose of VTE prophylaxis?
- Ask the nurse to get IV access, a full set of observations, and to uncover the patient so you can look for an infection source.
🧾 History
- Are they actually symptomatic, or was this an incidental high rate on observations?
- Known IHD, heart failure, or risk factors for ACS and thromboembolism.
- Caffeine (tea, coffee, energy drinks) and recent inhalers or nebs.
- Anticoagulants, antiplatelets, or NSAIDs if bleeding could be the cause of a compensatory tachycardia.
- Should they be on prophylactic LMWH, and has it been given? Missed prophylaxis belongs on the PE differential.
💊 Medication review
- Look for drugs that raise heart rate: frequent salbutamol, theophylline (toxicity), sympathomimetic eye drops such as phenylephrine, dipyridamole, anticholinergics, and excess levothyroxine.
- Check the BNF or local formulary for interactions before you add anything.
🩺 Examination
- ABCDE. Perfusion, capillary refill, and whether they are shocked or comfortable.
- Manual heart rate and pulse character (regular vs irregular).
- Volume status: dry mucosa, reduced skin turgor, JVP, oedema, and charted intake/output.
- Full exam for a source: chest, abdomen, skin, lines, wounds, and calves. Uncover the patient.
🧪 Investigations
- 12-lead ECG to confirm sinus tachycardia before you attribute the rate to a reversible cause.
- Directed bloods: FBC, U&E (including K⁺ and Mg²⁺), CRP. If febrile or septic, add cultures and lactate and start the local sepsis pathway.
- Group and save, and crossmatch if you think they are bleeding.
- Urine dip if infection or hypovolaemia from renal losses is plausible.
- Troponin if ACS is in the differential.
- D-dimer only when PE is a genuine consideration after clinical assessment (see Wells score). It is not a default test for every fast heart rate.
📌 Initial management
- Unwell patients need resuscitation first. Stable patients can follow a treat-the-driver plan.
- ABCDE. Monitor ECG, BP, and SpO₂. Give oxygen if SpO₂ <94%. IV access.
- Treat what is driving the tachycardia: analgesia, settle agitation and anxiety, rehydrate, antiemetics for vomiting, and the sepsis pathway where indicated. The rate often falls once those are dealt with.
- Step up nursing observations. If infection is likely, include frequent temperature checks.
- Seek expert help if the tachycardia persists despite treating reversible causes, or if you are unsure of the rhythm.
If the ECG shows a tachyarrhythmia
- Use the RCUK adult tachyarrhythmia algorithm at the top of this page with a senior present. Interns should not run that algorithm unsupervised.
- On the ECG, note QRS width (narrow vs broad) and whether the rhythm is regular or irregular. That is how RCUK branches the algorithm.
- Narrow irregular tachycardia is probable AF: compare old ECGs, involve a senior for rate control and anticoagulation decisions. See Atrial fibrillation for more.
- Do not cardiovert or give antiarrhythmics for sinus tachycardia.
Based on
Related NICE guidance
NICENICE NG196 — Atrial fibrillation: diagnosis and management
Full guidance on nice.org.uk. BetterCall is not endorsed by NICE.
Note Template
Ready-to-use clinical note structure
🕒 08 / 10 / 2026 — 16:08 ATRP re: tachycardia Patient: [age] [sex] Admission Dx: [reason for admission] PMHx: [IHD, heart failure, AF, other arrhythmia] 🧾 Hx: • Symptoms: [palpitations / chest pain / SOB / dizziness / syncope / none — incidental high rate] • Onset / duration: [__] • Old ECGs compared: [yes — same rhythm / different / none available] • Caffeine / nebs / new meds: [__] • VTE prophylaxis given: [yes / omitted / N/A] • Bleeding-risk drugs: [anticoagulant / NSAID / none] 💊 Chart review: • Rate-raising drugs: [salbutamol / theophylline / eye drops / other / none] • Rate-control already prescribed: [beta-blocker / digoxin / none] 🩺 Exam: • AVPU: [A / V / P / U] NEWS: __ • Manual HR: __ Regular/irregular: [regular / irregular] • BP: __ RR: __ Temp: __ SpO₂: __ CRT: __ • Perfusion: [comfortable / shocked] • Volume status: [dry / euvolemic / overloaded] • Infection source / bleeding: [none found / specify] 🧪 Investigations: • 12-lead ECG: [sinus tach / SVT / AF / flutter / VT / other] • Bloods: [FBC, U&E, CRP] lactate [ ] cultures [if febrile] • G&S / crossmatch: [if bleed suspected] • Urine dip: [ ] troponin: [ ] D-dimer: [only if PE suspected] 📋 Impression: Rhythm: [sinus tachycardia / tachyarrhythmia — specify] Likely driver: [pain / sepsis / hypovolaemia / PE / ACS / drug / primary arrhythmia / unclear] Haemodynamic status: [stable / unstable] 📌 Plan: • IV access, bloods, fluids if dry • RCUK tachyarrhythmia algorithm: [not indicated / indicated with senior present] • Treat driver: [analgesia / fluids / sepsis pathway / antiemetic / other] • Step up obs • Senior: [name / time / advice] 👤 [Your Name], [Role] IMC: _______
Educational reference only. Medical disclaimer