Chest pain in the Emergency department by Dr Shahid Bashir Chaudhary

1-Purpose:
1.1.Stabilization, symptom relief, and limitation of morbidity and mortality due
to 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, shortnes
s of breath).
3.PROTOCOL
3.1.High triage level is allotted if the chest pain is referred, somatic, visce
ral,
3.2.Initial assessment by ED Physician.
3.3.12 lead ECG performed and reviewed by within 10 minutes of presentation
3.4.If persistent ST elevation ≥ 1mm in 2 contiguous limb leads OR ST elevation ≥ 2m
m in 2 contiguous
3.5.chest leads OR new left bundle branch block pattern, proceed to STEMI contin
ue ECG monitoring as required.
3.6.Persistent ST elevation < identified above may represent transmural ischaemi
a or pericarditis and should be considered for further investigations including
early angiography.
4-Shift the patient in Resuscitation room.
4.1.If the patient has above changes on ECG and has retrosternal chest pain with
radiation 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 history
5.2.Location of pain
5.3.Provoking/palliative factor
5.4.Radiation
5.5.Severity 0-10
5.6.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 is
chemia, or may be due to bleeding associated with the source of pain (gastric ul
cer). Most authorities recommend maintenance of the hematocrit in a patient with
cardiac 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., sep
sis from delayed diagnosis of esophageal rupture).
6.1.2.Renal profile
Renal profile and elevated glucose may reveal previously unsuspected diabetes,
a risk factor for coronary artery disease.
6.1.3.Cardiac markers
Obtain an initial cardiac marker on arrival. Obtain a second marker at least 6 h
ours from chest pain onset for CK and 8 hours from onset for Troponin. Note that
serial marker testing excludes MI but does not exclude USA. ACEP: (American Col
lege of Emergency Physicians)
6.1.4.Amylase/lipase
When an abdominal source of pain is suspected, or tenderness is elicited in the
mid-epigastrium, pancreatitis should be considered. This is especially true in t
he presence of risk factors (alcohol use, biliary disease, and diabetes).
6.1.5.Urinalysis
Evaluation of the urine is rarely helpful in the chest pain patient, except when
glucosuria (pos- sible screen for diabetes) or bilirubinuria (possible screen f
or biliary duct obstruction or hepatic disease) are present.
6.1.6.Pregnancy test
Consider a pregnancy test in all female patients of childbearing age, especially
if they may undergo radiologic imaging.
6.1.7.D-dimer
D-dimers are degradation products of circulating cross-linked fibrin . D-dimer t
esting should only be performed when the type of test used is known to be sensit
ive for thromboembolism.
6.1.8.Arterial blood gas
Arterial 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 pa
tient with suspected PE,
6.1.9.Liver function tests
Liver 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.Electrocardiogram
An attempt should be made to perform an electrocardiogram (ECG) within 10 minute
s of arrival for all patients with unexplained chest pain (recommendation of the
American College of Emergency Physicians and the American College of Cardiology
). In studies of patients with AMI, ECGs are diagnostic in 30–50%, nonspecific in
40–70%, and normal in up to 10%. Findings of acute ischemia include new or presume
d new ST elevation, ST depression, or inverted T waves
American Heart Association guidelines recommend posterior and right-sided ECG le
ads when there are findings of ischemia such as ST elevation, ST depression, or
T-wave abnormalities on the traditional 12-lead ECG
6.1.11.Helical computed tomography
Helical CT may be extremely helpful in the evaluation of a stable patient with c
hest pain. It is reasonably sensitive (70 to 90%) and specific (90 to 95%) for PE
depending on scanner technology and the expertise of the radiologist.
6.1.1.2.Chest radiography
Chest radiography is most helpful when it points to a definitive diagnosis such
as pneumothorax or pneumonia. Although chest radiography is often normal or nons
pecific in conditions such as AMI, PE, and aortic dissection,
6.1.13.Echocardiography
This test can prove helpful in the evaluation of chest pain, especially in the u
nstable patient.Remarkable findings include valvular disease, pericardial effusi
on with tamponade physiology,
7.General treatment principles
7.1.Treatment begins with the ABCs. The goals of treatment are stabilization, sy
mptom relief, and limitation of morbidity and mortality due to the disease entit
y.
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 ischem
ia excluded)
• Complete H&P
• Provide pain relief
• Consider additional ECGs, radiologic and
• laboratory evaluation as indicated.
• Oxygen, 6L/min, via hudson mask, continuous (unless
• contraindicated, check with MO). Indication: chest pain or equivalent.
• Glyceryl Trinitrate, 300mcg to 600mcg, sublingual, every 5mins until pain reliev
ed 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, every
5 mins until pain relieved unless
• BP < 100mm Hg systolic.
8.High Risk Features
• High Risk Features: Presentation with clinical features consistent with acute co
ronary 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<0.40.
• Haemodynamic compromise – systolic blood pressure
< 90mmHg, cool peripheries, diaphoresis, Killip Class > 1and/or new onset mitral
regurgitation
• 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 Features
REFRENCE JCI
9.1.Resolved chest pain or discomfort within the past 48 hours that occurred at
rest, or was repetitive or prolonged (> 10mins)
9.2.Age > 65 years
9.3.No high-risk changes on electrocardiography (see above)
9.4.Chronic kidney disease - estimated GFR < 60mL/min (with atypical symptoms of
ACS)
9.5.Known coronary heart disease – prior myocardial infarct with left ventricular
ejection fraction >0.40, or known coronary lesion more than 50% stenosed
9.6.Two or more of the following risk factors: known hypertension, family histor
y, active smoking or hyperlipidaemia
9.7.Prior regular aspirin use
9.8.Presence of known diabetes (with atypical symptoms of ACS)
10. Low Risk Features
10.1.Presentation with clinical features consistent with ACS without intermediat
e risk or high risk features.
10.1.1.Examples: - onset of anginal symptoms within the last month or
10.1.1.1 worsening in severity or frequency of angina or
REFRENCE JCI
10.1.1.2 lowering in anginal threshold