PALPITASI

Pembimbing : dr. Yuddy, Sp.EM

Jeffri Prasetyo Utomo
Tania Putri Zahra
Evanti Tansil

INTRODUCTION

Definition
Perceptible unpleasant forcible pulsation of the heart, usually with
an increase in frequency or force, with or without irregularity in
rhythm.

Presentation
Most common outpatient complaint in patients presenting
to PCP and cardiologists
16% in one study of 500 patients
TermiAnology used:
Rapid fluttering in the chest
Flop-flopping in the chest
Pounding in the neck

 Cardiac:

Etiology

Arrhythmias
Cardiac and extracardiac shunts
Valvular heart disease
Pacemaker
Atrial myxoma
Cardiomyopathy

Panic disorders
Anxiety disorders
Somatization
Depression

Psychiatric:

 Medication:

Sympathomimetic
Vasodilators
Anticholinergic
-blocker withdrawal

Catecholamine Stress:
Exercise
Stress

Etiology

Cocaine
Amphetamines
Caffeine
Nicotine

Hab

Etiology
Metabolic disorders:

Hypoglycemia
Thyrotoxicosis
Pheochromocytoma
Mastocytosis
Scombroid Food Poisoning

Anemia
Pregnancy
Fever
Pagets disease

High output states:

Arrhythmic Etiologies

PAC/PVC
Sinus arrhythmias
SVT (AF, Aflutter, ORT, AVNRT, AT)
Idiopathic ventricular arrhythmias (RVOT, LVOT, fascicular
VT)
Life-threatening ventricular arrhythmias (MMVT, PMVT,
TdP, VFlutter, VF)

Predictors of Cardiac Etiology

Male gender
Reporting irregular heart beats
History of heart disease
Event duration > 5 minutes

History
Circumstances:
Association with anxiety or panic (20% of palpitations are
due to panic attacks and 67% of patients with SVT where
diagnosed at some point with panic disorder)
Association with stress (arrhythmias benign and fatal)
Association with position (AVNRT pr PAC/PVC)
Association with syncope or near-syncope (high level of
suspicion for VA)

Evaluation
Detailed History:

Age
Onset
Duration
Circumstances
Symptoms
Termination
Maneuvers (CSM, valsalva)
Regularity (tap out the rhythm)
Medications
Habits
Psychiatric disorders

 Physical Exam:

Evaluation

Rarely during palpitations

Auscultation (MVP, HCM, chronic
AF)

Evidence of CMP, valvular

disease, congenital abnormalities

Evaluation
12-Lead ECG:
PAC/PCV/SVT/VT
WPW
LVH/LAE/RAE
Long QT, Brugada, ARVD
Old MI
Conduction abnormalities
predisposing to TdP

CASE REPORT

Identitas

Nama
: Ny. LS
Register
: 1123xxxx
Jenis Kelamin
: Perempuan
Umur
: 42 th
Alamat
: Karanganyar, Poncokusumo
MRS
: 10 April 2015, pukul 11.25

Primary Survey
A : Patent
B : Gerakan dada simetris, RR 22
x/menit reguler, retraksi (-), Sat 02 96%.

C : TD: 150/90 mmHg, Nadi 96 x/menit

iregular, akral hangat, T.ax: 36,0 C, CRT
<2
D : GCS 456
Triage: P2

Intervensi Awal
A : B : O2 NC 4 lpm
C : IVFD NaCl 2000cc/24 jam

Anamnesa
Keluhan Utama: Berdebar
Pasien mengeluhkan dada berdebar debar sejak tadi
pagi jam 08.00 saat istirahat/ tidak beraktifitas,
timbul tiba tiba. Nyeri dada (-), sesak nafas (-),
tiba tiba terasa seperti mau pingsan. Riwayat
debar debar sebelumnya (+) 1 tahun yang lalu,
kadang kadang, timbul tiba tiba tanpa sebab,
hilang dengan istirahat. Riwayat DOE (-), PND (-),
kaki bengkak (-)
Riwayat HT (+) sejak 6 bulan yang lalu, TDS 150/,
tidak rutin kontrol

Riwayat Penyakit Keluarga: HT (-), DM (-), Asma (-), TB (-)

Riwayat Alergi: pasien tidak memiliki alergi

Secondary Survey

S
A
M
P
L
E

Palpitasi
No history for allergy
Never consume any
medication before

Gejala yang sama 1 tahun

yang lalu
4 jam SMRS

BP = 130/90 mmHg

General

PR =
97x/menit
iregular

Physical Examination
RR = 20x/menit

: Tampak sakit sedang

Head

Neck
Thorax

GCS 456
Anemis (-/-)

Pupil isokor 3mm/3mm

Icterik (-/-)

Reflek Cahaya +/+

JVP R + 0 cmH2O 300

Cor:

Ictus invisible palpable at ICS 5, MCL S

LHM ictus
RHM: SL D
S1, S2 single regular, murmur -, gallop -

Pulmo:

Tax : 36.5C

Simetris D=S, SF D=S

v|v rh - | - wh - | v|v

-|-

-|-

v|v

-|-

-|-

Abdomen

Datar, Soefl, traube space timpani, shifting dullness (-)

Extremities

Akral hangat, edema - | -|-

Findings

Result

Unit

Laboratory Findings

Normal value

Complete Blood Count

Hemoglobin

14,60

g/dL

13,4-17,7

Erythrocyte

4,71

104/mikroL

4,0-5,5

Leucocyte

6,39

103/mikroL

4,3-10,3

Hematocryte

41,20

40-47

Trombocyte

299

103/mikroL

142-424

MCV

87,50

fL

80-93

MCH

31,00

pg

27-31

MCHC

35,40

g/dL

32-36

-Eos

0,0

0-4

-Ba

0,2

0-1

-Neu

75,8

51-67

-Lim

18,5

25-33

-Mono

5,5

2-5

GDS

86

Mg/dL

<200

Natrium

139

Mmol/L

136-145

Kalium

4,15

Mmol/L

3,5-5,0

Chloride

116

Mmol/L

98-106

Diff Count

Electrolyte

Findings

Result

Laboratory Findings

Unit

Normal value

Faal Hati
SGOT

10

U/L

0-40

SGPT

11

U/L

0-41

Albumin

g/dL

3,5-5,5

Ureum

15,80

mg/dL

16,6-48,5

Kreatinin

0,64

mg/dL

<1,2

Faal Ginjal

Analisa Gas Darah

pH

7,38

7,35 - 7,45

pCO2

27,2

mmHg

35-45

pO2

127,5

mmHg

80-100

HCO3

16,4

mmol/L

21-28

BE

-8,9

mmol/L

(-3) (+3)

Saturasi O2

98,8

>95

Hb

13,3

g/dL

Suhu

37,0

Troponin I

0,37

Mikrog/L

<1

CK-NAC

50

U/L

26-192

CK-MB

18

U/L

7-25

Enzim Jantung

EKG 10 April 2015 jam 7.10

EKG 10 April 2015 jam 10.19

10 april 2015 11.25

10 april 2015 13.15-13.21

10 april 2015 18.05 pasca drip

amiodarone 1 jam

19.40

Thorax

Diagnose
Supraventricular Tachycardi

Theraphy
O2 2-4 lpm NC
IVFD NS 0,9% 2000 cc/24 jam
Loading amiodarone->

Monitoring
Vital Sign
Subjective
ECG serial

DISCUSSION

1. Perempuan, 42 tahun mengalami berdebar 3 jam SMRS,

2.
3.
4.
5.

riwayat berdebar sejak 1 tahun yang lalu, sesak (-), PND (-),
DOE (-), bengkak (-), riwayat DM dan HT(-).
Pemeriksaan fisik: TD 150/90 mmHg, N 96x/menit iregular, RR
22x/menit, Tax 36,0 0C.
EKG: SVT
Lab: Terapi: O2 4 lpm via Nasal canul, IV line IVFD NaCl 0.9%
maintanance 2000cc?24 jam

. Berdasarkan data dari primary dan secondary survey, kita

membuat kesimpulan pasien mengalami palpitasi dt SVT

 Tachycardia refers to a heart rate >100 bpm. The

tachycardia may be supraventicular or ventricular
depending of the origin og the arrithmya.
SVT is a narrow complex tachycardia originating in
propagation outside the sinus node but above the
bifurcation of the bundle of His, with rate that exceed 100
bpm.

Therapy

Pharmacological therapy
ABCD are the drug of choice (adenosin, beta blocker, CCB, digoxin)
Adenosin should not be given if the patient have bronchospastic pulmonary
disease because can precipitate asthma. Initial dose is 6 mg given IV bolus. The
injectiion should given rapidly in 1 to 2 second follow by saline flush. If not
converted to normal synus 12mg bolus is given IVthird and final dose 0f 12
mg may be repeated if the tachycardia has not responded.
Beta Blocker ( metoprolol, atenolol, propanolol, esmolol). Should not be given if
there is congestive heart failure.

 CCB verapamil or diltiazem. If the patient is not hypitnesis 2.5 5

mg of verapamil is give on IV slowly over to minute under carefull
ECG and blood pressure monotoring, if there is no response and the
patient remain stable, additional dose of 5-10 mg maybe given every
15 30 minutes until total dose of 20 mg is given.
Digoxin has slowe onset of action and is not as effective as
previously discussed agents. The initial dose of digoxin agent in a
patient who is not on oral digoxin is 0.5 mg given slowly IV for 5
minutes or longer. Subsecuent doses of 0.25 mg IV should be given
after 4hr and repeated if needed for a total dose of no more than 1.5
mg over 24 hr period.
Other Antiarhtymia agent that should be considered include type 1A
(procainamide) 1C (propafenon) or type 3 agent (amiodaron, ibutilit).
The use of this agent. Requires expert consultation. This agent
should be considered only if SVT is resistant to above pharmacologic

Discussion
Primary survey
1. A : 2. B : O2 NC 4 lpm
3. C : IVFD NaCl 2000cc/24 jam

Klinis
Found

Jantung berdebar debar, dan riwayat berdebar-debar

sejak 1 tahun lalu

Theory

Palpitation - greater than 96 %

Tiba-tiba terasa seperti mau pingsan

Lemas

Dizziness - 75%

Shortness of breath - 47%

Chest pain -35%

Syncope -20%
Fatigue - 23%

Diaphoresis 17%

Nausea 13 %

Therapy
O2 2-4 lpm NC
IVFD NS 0,9% 2000 cc/24 jam
Loading amiodarone-> 150 mg IV bolus in 10
minute( 15mg/minute), followed by 360 mg over next 6
hours (1mg/minute).

Lesson Learnt

 Palpitasi merupakan perasaan subjektif pasien berupa

rasa tidak nyaman/ bergetar/ nyeri di dada atau daerah
anatomis disekitarnya yang dapat terjadi mendadak atau
perlahan
Palpitasi dapat disebabkan oleh karena gangguan pada
jantung, kondisi psikologis, penggunaan obat-obatan,
maupun gangguan elektrolit
Tatalaksana dari palpitasi yaitu antiaritmia (amiodarone),
calsium channel blocker (verapamil/diltiazem)

TERIMA KASIH