• Check for cardiac murmurs, and note no S3 or S4
• Full skin exam—selective for GU area/breasts if asymptomatic.
• Palpate the back and percuss costovertebral angle
• Check feet/toes in diabetic patients
• Check for signs of peripheral embolization.

Do I need to admit all patients with persistent tachycardia?

No. Admitting all patients with tachycardia would create more preventable mortality and morbidity through nosocomial and iatrogenic complications, which are not to be ignored. But if you are discharging 20 percent of your patients with persistent tachycardia, that is probably too high. For example, about 16 percent of patients who meet sepsis criteria are discharged, and they have measurable increased risk.¹⁴ In our own experience with infectious diagnoses, we found that a rate of discharge around 10 percent reduces claims by 50 percent. This strikes a good balance between sepsis capture versus over-capture with nosocomial/iatrogenic complications. A significant number of patients can be discharged with no complications but choose them carefully. Most importantly, consider any patient with persistent tachycardia as having double the risk as a matched patient with no tachycardia, and take a pause to consider if the patient might have sepsis, MI, PE, Acute Cardiomyopathy/CHF. Take patient frailty into account. A study using Charlson Comorbidity Index found that an index of 4 or more triples the chances of unexpected death after discharge.¹⁵

What If I Do Discharge a Patient?

The discussion with the patient, documentation, and discharge instructions are the key elements to defending you good care. Explain to the patient what you did to look for dangerous causes of tachycardia, and explain that, in the absence of these findings, the risk is low. Document patient capacity, understanding, and assent. Consider a 24-hour follow-up in the ED for patients you discharge.

Takeaways

The four main killers after discharge with unexplained tachycardia:

1. Sepsis
2. Pulmonary Embolism
3. Myocardial Infarction
4. Acute Cardiomyopathy/Congestive Heart Failure

Depending on the chief complaint and history, there are high risk features you can search for on history and physical exam. If they are present, one or more of the following tests can be a valuable follow-on screening tool: Lactate, Troponin, BNP, D-Dimer, and ECG.

In the setting of persistent tachycardia, a thorough history and physical with attention to finding pertinent negatives and will be appreciated by the patient, enhance you reputation is a physician, and make your care more defendable.

Dr. Bedolla is national director of risk science at US Acute Care Solutions and assistant professor at the University of Texas Dell Medical School.