Download Chest Pain

Adult Emergency Nurse Protocol
20XX
CHEST PAIN (suspected cardiac)
Aim:
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Early identification and treatment of life threatening causes of chest pain, escalation of care for patients at risk.
Early initiation of treatment / clinical care and symptom management within benchmark time.
Consistent use of the NSW Ministry of Health Chest Pain Pathway PD2011_037
Assessment Criteria: On assessment the patient should have one or more of the following signs / symptoms:
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Chest pain within the past 48hrs
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Syncope
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Jaw pain
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Sudden Othoponea/ Dyspnoea
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Epigastric discomfort
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Arm pain
Escalation Criteria: Immediate life-threatening presentations that require escalation and referral to a Senior Medical Officer (SMO):
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Myocardial Infarction
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Cardiogenic Shock
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Traumatic Chest Injury
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Tension Pneumothorax
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Suspected Pulmonary Emboli
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Life Threatening Arrhythmia
 Coronary Dissection
 Hypotension & tachy / bradycardia
 Acute confusion / agitation
Primary Survey
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Airway: patency
Circulation: perfusion, BP, heart rate, temperature
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Breathing: resp rate, accessory muscle use, air entry, SpO2.
Disability: GCS, pupils, limb strength
Notify CNUM and SMO if any of the following red flags is identified from Primary Survey and Between the Flags criteria.
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Airway – at risk
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Breathing – respiratory distress
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Circulation – shock / altered perfusion
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Partial / full obstruction
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RR < 5 or >30 /min
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HR < 40bpm or > 140bpm
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SpO2 < 90%
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BP < 90mmHg or > 200 mmHg
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Disability – decreased conscious level
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Exposure
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Postural drop >20mmHg
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GCS ≤ 14 or a fall in GCS by 2
points
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Temperature < 35.5°C or > 38.5°C
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Capillary return > 2 sec
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BGL < 3mmol/L or > 20mmol/L
History:
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Presenting complaint
Allergies
Medications: Anticoagulant Therapy, Anti-hypertensives, Diabetic meds, Analgesics, Inhalers, Chemotherapy, Non-prescription
meds, Any recent change to meds
Past medical past surgical history relevant – hypertension; family history of IHD; smoker; high cholesterol; chronic renal failure;
diabetes; age > 65 years
Last ate / drank & last menstrual period (LMP)
Events and environment leading to presentation
Pain Assessment / Score: PQRST (Palliating/ provoking factors, Quality, Region/radiation, Severity, Time onset)
Associated signs / symptoms: epigastric, back or throat pain, radiation to back / neck / arm, nausea, syncope, pale, diaphoresis.
Systems Assessment:
Focused cardiovascular assessment:
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Inspection: trachea midline; general appearance – skin colour / capillary return < 2 sec; chest wall abnormalities; equal expansion of
the chest during inspiration.
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Auscultation: equal breath sounds ; heart sounds
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Palpation: central & peripheral pulses; localised chest wall tenderness
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Percussion over the chest wall: Tympani over air filled organs; Dullness over fluid filled organs and bone
Notify CNUM and SMO if any of the following red flags is identified from History or Systems Assessment.
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Deviated trachea
Ischemic ECG changes
Arrhythmia
Elderly > 65 years
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Abnormal heart sounds
Abnormal breath sounds
Asymmetrical chest wall movements
Family Hx Cardiac disease
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Diaphoresis / Pallor
Syncope / LOC
Bruising to chest wall
Smoker
Investigations / Diagnostics:
Bedside:
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Commence patient on a chest pain pathway
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ECG: completed and reviewed within 10 min of the
patient’s presentation - look for Arrhythmia , AMI 
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BGL: If < 3mmol/L or >20mmol/L notify SMO 
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Urinalysis / MSU: if urinary symptoms present
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Chest Pain (suspected cardiac) – Adult Emergency Nurse Protocol
Laboratory / Radiology:
Pathology: Refer to local nurse initiated STOP
Troponin, FBC, EUC, Coags (anticoagulant therapy)
Urine βHCG & Quantitative ßHCG if positive
Group and Hold (if bleeding suspected)
Blood Cultures (if Temp >38.5 or <35°C)
Radiology: Refer to local nurse initiated STOP - Chest X-ray
(discuss with SMO)
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Adult Emergency Nurse Protocol
20XX
CHEST PAIN (suspected cardiac)
Nursing Interventions / Management Plan:
Resuscitation / Stabilisation:
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Oxygen therapy (SpO2< 93%)
Continuous cardiac monitoring [as indicated]
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IV Cannulation (consider large bore i.e. 16-18gauge)
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IV Fluids: Sodium Chloride 0.9% 1 L IV stat versus over 8
hours (discuss with SMO)
Symptomatic Treatment:
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Antiemetic: as per district standing order
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Analgesia: as per district standing order
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IV Fluids: as per district standing order
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Aspirin: 300mg orally (as per nurse initiated medications)
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Glyceryl Trinitrate: 600microg sublingually (as per nurse initiated
medications)
Supportive Treatment:
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Nil By Mouth (NBM)
Continuous cardiac monitoring [as indicated]
Monitor vital signs as clinically indicated
(BP, HR, T, RR, SpO2)
Monitor neurological status GCS [as indicated]
Monitor pain assessment / score
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Fluid Balance Chart (FBC)
Repeat ECG 30 min after the first ECG
Repeat ECG with return of chest pain
Serial ECGs (6-8 hourly)
Serial Troponin (3hrs and/or 6hrs)
Practice Tips / Hints:
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High risk chest pain patients require continuous cardiac monitoring i.e. ACS, cardiac arrhythmias; syncope / LOC; electrolyte
imbalance; pharmacotherapy (4)
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Requires direct visual observation until monitoring has been discontinued
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Discontinuation of cardiac monitoring requires a written medical order in the patients records (4)
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Patient transfers require an appropriately trained escort and cardiac monitoring equipment
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Escalate, document and review any abnormalities to a Senior Medical Officer
(4)
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Further Reading / References:
1.
SESLHD Patient with Acute Condition for Escalation (PACE): Management of the Deteriorating Adult and Maternity Inpatient SESLHD/PR283.
http://www.seslhd.health.nsw.gov.au/Policies_Procedures_Guidelines/Clinical/Other/SESLHDPR283-PACEMgtOfTheDeterioratingAdultMaternityInpatient.pdf
2.
Chew, D. P., Aroney, C. N., Aylward, P. E., Kelly, A., White, H. D., Tideman, P. A., Waddell, J., Azadi, L., Wilson, A. J., & Ruta, L. M. (2011). 2011
Addendum to the National Heart Foundation of Australia/ Cardiac Society of Australia and New Zealand Guidelines for the Management of Acute
Coronary Syndromes (ACS) 2006. Retrieved on the 29/05/2013 from: http://www.heartfoundation.org.au/SiteCollectionDocuments/2011-ACSaddendum-article-in-press.pdf
3.
National Heart Foundation of Australia/ Cardiac Society of Australia and New Zealand (2006). Guidelines for the management of acute coronary
syndromes 2006 - Summary of key recommendations. Retrieved on the 29/05/2013 from:
http://www.heartfoundation.org.au/SiteCollectionDocuments/acs-guidelines-mja-summary.pdf
4.
NSW Health. (2008). Cardiac Monitoring in Adult Cardiac Patients in Public Hospitals in NSW. Retrieved on the 28/05/2013 from:
http://www0.health.nsw.gov.au/policies/pd/2008/pdf/PD2008_055.pdf
5.
NSW Health. (2011). Chest Pain Evaluation (NSW Chest Pain Pathway). Retrieved on the 28/05/2013 from:
http://www0.health.nsw.gov.au/policies/pd/2011/pdf/PD2011_037.pdf
6.
NSW Health. (2007, October 18th). Medication Handling in NSW Public Hospitals. Retieved on the 28/05/2013 from
http://www0.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_077.pdf
7.
SGSHHS (2011). Medications - Nurse/ Midwife initiated. Retrieved on the 28/05/2013 from:
http://seslhnweb/SGSHHS/Business_Rules/Clinical/documents/M/medications_nurse_initiated_SGSHHS_CLIN098.pdf
8.
Woods, Susan L., Sivarajan Froelicher, Erika S., Adams (Underhill) Motzer, Sandra, Bridges, Elizabeth J. (2010). Assessment of Heart Disease History Taking and Physical Assessment (Chapter 10). In Cardiac Nursing (6th Edition). Retrieved from: http://ovidsp.tx.ovid.com/sp3.8.1a/ovidweb.cgi?&S=DLDBFPAIIODDKFMANCOKPAGCHDFDAA00&Link+Set=S.sh.20%7c9%7csl_10
Acknowledgements: SESLHD Adult Emergency Nurse Protocols were developed & adapted with permission from:
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Murphy, M (2007) Emergency Department Toolkits. Westmead Hospital, SWAHS
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Hodge, A (2011) Emergency Department, Clinical Pathways. Prince of Wales Hospital SESLHD.
Revision & Approval History
Date
Revision No.
Author and Approval
Chest Pain (suspected cardiac) – Adult Emergency Nurse Protocol
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