8/6/2019 chest pain protocol in ED

1/3

Chest pain in the Emergency department by Dr Shahid Bashir Chaudhary

1-Purpose:1.1.Stabilization, symptom relief, and limitation of morbidity and mortality dueto the disease entity.2.Policy:2.1.This protocol can only be used for patients that have:

2.2.A complaint of chest discomfort (non-traumatic) or jaw, shoulder, arm, back,or epigastric pain. Consider other atypical features (eg. diaphoresis, shortness of breath).3.PROTOCOL3.1.High triage level is allotted if the chest pain is referred, somatic, visceral,3.2.Initial assessment by ED Physician.3.3.12 lead ECG performed and reviewed by within 10 minutes of presentation3.4.If persistent ST elevation 1mm in 2 contiguous limb leads OR ST elevation 2mm in 2 contiguous3.5.chest leads OR new left bundle branch block pattern, proceed to STEMI continue ECG monitoring as required.

3.6.Persistent ST elevation < identified above may represent transmural ischaemia or pericarditis and should be considered for further investigations includingearly angiography.4-Shift the patient in Resuscitation room.4.1.If the patient has above changes on ECG and has retrosternal chest pain withradiation to limbs ,back or jaw,4.2.Patient is breathless with above ECG changes.4.3Patient has sweating , chest pain and ECG changes.4.4.Patient is having risk factors with above mentioned ECG changes.

5- Proceed for Secondary assessment if patient is excluded from above criteria.5.1.Medical history5.2.Location of pain

5.3.Provoking/palliative factor5.4.Radiation5.5.Severity 0-105.6.Timing (duration and onset)5.7.Associated symptoms

6-DIAGNOSTIC TEST.6.1.LAB Studies;6.1.1.CBC: A low hema- tocrit may indicate a reason for symptoms of car- diac ischemia, or may be due to bleeding associated with the source of pain (gastric ulcer). Most authorities recommend maintenance of the hematocrit in a patient withcardiac ischemia above 30 mg/dl to maximize O2 delivery. A high white count may

represent demargination due to stress, pain, or a catastrophic event (e.g., sepsis from delayed diagnosis of esophageal rupture).6.1.2.Renal profileRenal profile and elevated glucose may reveal previously unsuspected diabetes,a risk factor for coronary artery disease.6.1.3.Cardiac markersObtain an initial cardiac marker on arrival. Obtain a second marker at least 6 hours from chest pain onset for CK and 8 hours from onset for Troponin. Note thatserial marker testing excludes MI but does not exclude USA. ACEP: (American College of Emergency Physicians)

6.1.4.Amylase/lipaseWhen an abdominal source of pain is suspected, or tenderness is elicited in the

mid-epigastrium, pancreatitis should be considered. This is especially true in the presence of risk factors (alcohol use, biliary disease, and diabetes).6.1.5.Urinalysis

8/6/2019 chest pain protocol in ED

2/3

Evaluation of the urine is rarely helpful in the chest pain patient, except whenglucosuria (pos- sible screen for diabetes) or bilirubinuria (possible screen for biliary duct obstruction or hepatic disease) are present.6.1.6.Pregnancy testConsider a pregnancy test in all female patients of childbearing age, especiallyif they may undergo radiologic imaging.6.1.7.D-dimer

D-dimers are degradation products of circulating cross-linked fibrin . D-dimer testing should only be performed when the type of test used is known to be sensitive for thromboembolism.6.1.8.Arterial blood gasArterial blood gas sampling is useful to assess ventilatory status (CO2 level),serum pH, and to confirm a low pulse oximetry reading. In the assessment of a patient with suspected PE,6.1.9.Liver function testsLiver function tests may be elevated in patients with biliary or hepatic disease, or due to passive congestion of the liver in heart failure.6.1.10.ElectrocardiogramAn attempt should be made to perform an electrocardiogram (ECG) within 10 minute

s of arrival for all patients with unexplained chest pain (recommendation of theAmerican College of Emergency Physicians and the American College of Cardiology). In studies of patients with AMI, ECGs are diagnostic in 3050%, nonspecific in4070%, and normal in up to 10%. Findings of acute ischemia include new or presumed new ST elevation, ST depression, or inverted T wavesAmerican Heart Association guidelines recommend posterior and right-sided ECG leads when there are findings of ischemia such as ST elevation, ST depression, orT-wave abnormalities on the traditional 12-lead ECG

6.1.11.Helical computed tomographyHelical CT may be extremely helpful in the evaluation of a stable patient with chest pain. It is reasonably sensitive (70 to 90%) and specific (90 to 95%) for PEdepending on scanner technology and the expertise of the radiologist.

6.1.1.2.Chest radiographyChest radiography is most helpful when it points to a definitive diagnosis suchas pneumothorax or pneumonia. Although chest radiography is often normal or nonspecific in conditions such as AMI, PE, and aortic dissection,6.1.13.EchocardiographyThis test can prove helpful in the evaluation of chest pain, especially in the unstable patient.Remarkable findings include valvular disease, pericardial effusion with tamponade physiology,

7.General treatment principles7.1.Treatment begins with the ABCs. The goals of treatment are stabilization, symptom relief, and limitation of morbidity and mortality due to the disease entity.7.2.Initial assessment and interventions ABCs Patient appearance Vital signs including O2 saturation Place IV line, administer O2, and place on cardiac monitor ECG within 10 minutes of arrival Directed H&P (includes pulmonary and CVS)7.3.Secondary assessment and interventions ASA 325 mg po (unless patient allergy, appropriate dose already taken, or ischemia excluded) Complete H&P Provide pain relief

Consider additional ECGs, radiologic and laboratory evaluation as indicated. Oxygen, 6L/min, via hudson mask, continuous (unless

8/6/2019 chest pain protocol in ED

3/3

contraindicated, check with MO). Indication: chest pain or equivalent. Glyceryl Trinitrate, 300mcg to 600mcg, sublingual, every 5mins until pain relieved unless BP < 100mm Hg systolic. Indication: chest pain or equivalent up to 15 minutes then consider morphine. Morphine sulphate, 2.5mg to 5mg, intravenous, maximum 10mg then MO review, every5 mins until pain relieved unless

BP < 100mm Hg systolic.

8.High Risk Features High Risk Features: Presentation with clinical features consistent with acute coronary syndromes (ACS) and one: Repetitive or prolonged (> 10 minutes) ongoing chest pain or discomfort Elevated level of at least one cardiac biomarker - Troponin Persistent or dynamic ECG changes of ST-segment depression 0.5mm or new T-wave inversion 2mm Transient ST-segment elevation ( 0.5mm) in more than two contiguous leads

Left ventricular systolic dysfunction (left ventricular ejection 1and/or new onset mitralregurgitation Sustained ventricular tachycardia Syncope Prior percutaneous coronary intervention within 6 months or prior coronary artery bypass surgery Presence of known diabetes (with typical symptoms of ACS) Chronic kidney disease - estimated GFR < 60mL/min (with typical symptoms of ACS)9. Intermediate Risk FeaturesREFRENCE JCI

9.1.Resolved chest pain or discomfort within the past 48 hours that occurred atrest, or was repetitive or prolonged (> 10mins)

9.2.Age > 65 years9.3.No high-risk changes on electrocardiography (see above)9.4.Chronic kidney disease - estimated GFR < 60mL/min (with atypical symptoms ofACS)9.5.Known coronary heart disease prior myocardial infarct with left ventricularejection fraction >0.40, or known coronary lesion more than 50% stenosed9.6.Two or more of the following risk factors: known hypertension, family history, active smoking or hyperlipidaemia9.7.Prior regular aspirin use9.8.Presence of known diabetes (with atypical symptoms of ACS)10. Low Risk Features10.1.Presentation with clinical features consistent with ACS without intermediate risk or high risk features.10.1.1.Examples: - onset of anginal symptoms within the last month or10.1.1.1 worsening in severity or frequency of angina orREFRENCE JCI10.1.1.2 lowering in anginal threshold