Download Chest pain - Acute coronary syndrome (unstable angina

File 18 cardiovascular emergencies
 Chest pain
Acute coronary syndrome (unstable angina, myocardial infarct)
Recommend
 Management is determined by clinical presentation, results of the ECG and
blood tests
 Consider acute coronary syndrome (myocardial infarct or unstable angina) in
all people who present with chest pain that is new, recurrent, increasingly
frequent or long-lasting until ECG is performed and that is ruled out [1]
 Recent studies have shown that patients who receive blood clot dissolving
medication (eg Tenecteplase) thrombolysis within 90 minutes of a
myocardial infarct have a much better recovery / outcome [2]
 Streptokinase should not be used in Aboriginal and Torres Strait Islander
patients or those who have received streptokinase more than 3 days
previously [3]
Background
 Ischaemic heart disease is where the blood supply through the coronary
arteries is insufficient to supply the needs of the heart muscle
 Angina pain is transient and subsides promptly with rest or Glyceryl Trinitrate
(GTN). Usually precipitated by exertion, eating, emotion or cold. No
permanent damage to the heart muscle has occurred.

stable angina – is when the symptoms have not changed for the past
month

unstable angina / acute coronary syndrome – symptoms come on at
rest or with minimal exertion, increase in severity and duration despite
treatment and are slow to resolve with acute treatment (rest, GTN,
oxygen)
 Heart attack (myocardial infarct) is associated with severe pain that may occur
at rest and is not relieved by rest or GTN. Part of the heart muscle dies. A
myocardial infarct is divided into ST elevation myocardial infarct (STEMI) and nonST elevation myocardial infarct (NSTEMI)
Related topics:
DRABC Resuscitation / the collapsed patient, page 35
 Cardiac arrest, page 40
 Cardiac arrhythmias, page 89
 Acute pulmonary oedema, page 87
 Trauma and injuries, page 95
 Alcohol related epigastric pain, page 169
 Acute abdominal pain, page 165
1.
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May present with:
Chest pain
Hypotension
Collapse / cardiac arrest
Irregular heart beat
Breathlessness
Confusion (especially if
elderly)
File 18 cardiovascular emergencies

Beware unusual presentation in older patients, people with diabetes and women
Acute coronary syndrome
(ischaemic heart disease, angina, heart attack)
 Central chest pain, may be mild or severe (people with diabetes may not feel the pain of a heart
attack)
 Pain is often crushing, and left sided
 Pain may radiate to neck, jaw, shoulders, arms, back
 May or may not be associated with:
 nausea, vomiting
 fainting or light headed
 palpitations
 pale and sweating
 breathlessness, cyanosis (blue around the lips, fingers)
 fatigue, confusion, loss of consciousness
 indigestion
Pericarditis pain
 Pain can be similar to angina
 Pain typically lasts for hours
 Usually worse on deep inspiration
 Classically worse when lying flat and relieved by sitting upright / leaning forward
Chest infection with pleurisy pain
 Chest pain – sharp and worse on inspiration
 Breathlessness
 Chest wheezes or crackles (rubs)
 Cough with purulent or blood stained sputum
 Fever
 May have no infective signs if viral pleurisy
 see Pneumonia
Chest pain from injury
 Chest pain associated with blunt or penetrating injury
 see Trauma and injuries
Oesophageal pain
 Central pain – upper abdomen, lower sternum, burning in nature, worse on lying down
 Difficult to differentiate from angina
 see Alcohol related epigastric pain
Dissecting thoracic aortic aneurysm pain (aortic aneurysm)
 Severe chest pain begins suddenly
 Pain described as sharp, stabbing, tearing or ripping
 Central chest pain classically radiating directly back between the shoulder blades
 Consult MO immediately
Biliary colic
 Can sometimes present with central chest pain or right subcostal pain
 Usually colicky in nature
Acute abdominal pain
 Upper abdominal / lower chest pain associated with abdominal symptoms and tenderness
 See Acute abdominal pain
2.
Immediate management of chest pain:
DRABC Resuscitation / the collapsed patient
 Give high flow oxygen
 Perform BP, heart rate – (check – strength, rate and regularity), respiration rate and oxygen
saturation
 Do ECG fax to MO. (Send copy of previous ECG - if available. This should not delay sending new
ECG to MO)
 Insert IV cannula
 Consult MO as soon as possible
3.
Clinical assessment:
 Do 12 lead ECG (if not already done)
 As part of patient history identify:
 previous history of similar episodes of pain
File 18 cardiovascular emergencies
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past medical and surgical history – particularly note hypertension, dyslipidaemia, diabetes
note any family history of angina, heart attacks, stents or coronary bypass surgery, elevated
cholesterol
 smoking status
Take medication history - current medications, allergies
Perform standard clinical observations + oxygen saturation AND take BP on both arms (a difference
of > 20mmHg between right and left arm suggests dissection). Note any palpations / irregular heart
rate
The pain
 how severe is the pain? (scale of 1 to 10, with 10 being the worst)
 if severe chest pain, assessment may be easier after analgesia is given. Consult MO
 when did it start? – note time when pain started and resolved
 where is the pain?
 is the pain sharp or dull?
 does the pain radiate anywhere eg. to the arm, or neck or jaw, or back?
 is the pain worse with movement, coughing or taking a deep breath?
 was it associated with exertion?
 are there any associated symptoms eg. nausea, vomiting, sweating, fever, cough with purulent or
pink frothy sputum or blood, breathlessness, faintness?
Perform physical examination – use the table to guide possible causes of chest pain
 palpate the chest wall – is there any tenderness?
 auscultate the chest for air entry and added sounds (wheezes and crackles)
 palpate the abdomen for tenderness: acute abdominal problems can present as chest pain and
vice versa, see Acute abdominal pain
Report findings to MO
Probable cause of chest
pain
Acute coronary syndrome
(unstable angina) heart
attack)
Chest infection with
pleurisy
Symptoms and signs
- central retrosternal pain described as a tightness or
crushing feeling in chest
may radiate to the arm, or neck or jaw
- may have associated nausea, vomiting, pallor, sweating,
breathlessness
-sharp chest pain, worse on deep breath may have reduced
air entry or wheezes and crackles in the lungs
What to do
Oxygen
Aspirin
GTN
Thrombolysis
See Management under 4.
See Pneumonia
Pulmonary embolus (blood
clot in the lungs) secondary
to Deep Vein Thrombosis
(DVT)
- sharp chest pain, may be worse with breathing, may cough
up blood
- think of it in pregnant women or post natal women, people
who have had an operation in the past 2 months, and older
people who have spent a long time without much movement
(eg. after a long journey sitting down or after a long time in
bed in hospital) especially if they have a painful or swollen
leg
Chest injuries
- chest pain associated with chest injuries
See Chest injuries
Oesophageal pain
- burning retrosternal pain, worse on lying down
- may by associated with a sensation of fluid in the back of
the throat (“water brash”)
- often associated with pregnancy, obesity, alcohol and a
history of “indigestion”
Do ECG and fax to MO
Consult MO who may advise
antacid 20 mL stat & / or
Metoclopramide 10 mg IM
stat. See Alcohol related
epigastric pain
Abdominal Pain
- chest/lower abdominal pain associated with abdominal
symptoms or tenderness
Do ECG & fax to MO See
Acute abdominal pain
Consult MO urgently.
Evacuating / attending MO
may consider heparinisation
File 18 cardiovascular emergencies
Dissecting thoracic aortic
aneurysm
- severe chest pain begins suddenly
- pain described as sharp, stabbing, tearing or ripping
- felt below the chest bone, then moves under the shoulder
blades or to the back, - neck, arm, jaw abdomen or hips
- pain moves to the arms and legs as the aortic dissection
gets worse
- may be found in young otherwise well people
Consult MO immediately
NO THROMBOLYSIS
medication
4. Management acute coronary syndrome:
 Continue high flow Oxygen
 Give Aspirin 300 mgs dissolved in water (provided not already given or contraindicated)
 Perform BP, heart rate, respiration rate and oxygen saturation
 Insert IV cannula - collect blood for baseline Troponin levels, on admission, then 6-8 hours after
presentation [4]
 Give sublingual GTN provided not hypotensive. Note: do not give GTN if has taken Viagra® in the last
24 hours
 if ECG shows STEMI myocardial infarct and criteria met, MO will order Tenecteplase:
Schedule
2
DTP
IHW / NP
Soluble Aspirin
Authorised Indigenous Health Workers may proceed
Nurse Practitioners may proceed
Route of
Form
Strength
Administration
Tablet
300 mg
Oral
Recommended Dosage
Duration
Adults only: 300 mg
Dissolve in small amount of water or chewed
Stat
Provide Consumer Medicine Information if available:
Management of Associated Emergency: Consult MO
Schedule
3
Glyceryl Trinitrate (GTN)
Authorised Indigenous Health Workers may proceed
Nurse Practitioners may proceed
Route of
Recommended
Form
Strength
Administration
Dosage
Tablet 0.6 mg
Sublingual
Adults only: 0.6 mg
provided not
hypotensive
ie. Systolic
BP not <100
mmHg
Spray
400
Sublingual
Adults only: one to
microgram/do
two sprays
se: in 14.7
mL.
DTP
IHW / NP
Duration
Stat. If pain persists
can repeat after 5 min
again provided not
hypotensive and no
headache from initial
GTN
Stat. If pain persists
can repeat after 5 min
again provided not
hypotensive and no
headache from initial
GTN
Provide Consumer Medicine Information if available: do not give GTN if has taken Viagra® in the
last 24 hours
Management of Associated Emergency: Consult MO

if ECG shows STEMI myocardial infarct and criteria met, MO will order Tenecteplase:
File 18 cardiovascular emergencies
ST elevation myocardial infarct
(STEMI)
Normal results
or results
unchanged from
previous ECG
New left bundle
branch block pattern
Indications for thrombolysis (Tenecteplase)
Ischaemic chest pain lasting at least 30 minutes, not relieved by nitrates
AND
Onset of chest pain less than 12 hours previously
AND
Persistent ST segment elevation: 1mm or more in 2 adjacent limb leads or V4-6 or 2mm or more in leads V1-3
OR
New left bundle branch block

If the above criteria is met the MO will advise to give patient
 Tenecteplase
 Enoxoparin 1mg / kg subcutaneously
 Enoxaparin 30mg IV
 Clopidogrel 300mg orally
Schedule
4
Form
Strength
Ampoule
50mg in 10
mL water
Tenecteplase (Metalyse)
NON DTP
Tenecteplase must be ordered by a Medical Officer
Route of administration
Recommended dose
30-50mg (over 10 seconds)
(up to 50mg on basis of body weight)
IV
< 60 kg – IV 30mg
60-70 kg – IV 35mg
70-80 kg – IV 40mg
80- 90 kg – IV 45 mg
> 90 kg – IV 50 mg
Contraindications for thrombolysis
* Absolute:
Active bleeding or bleeding diathesis
(excluding menses)
 Significant closed head or facial
trauma within 3 months
 Suspected aortic dissection
 Any prior intracranial haemorrhage
 Ischaemic stroke within 3 months
 Known structural cerebral vascular
lesion
 Known malignant intracranial
neoplasm
Relative
 Current use of anticoagulants
 Non-compressible vascular punctures
 Recent major surgery (< 3 weeks)
 Traumatic or prolonged >10min CPR
 Recent internal bleeding (within 4 weeks)
 Active peptic ulcer
 History of chronic, severe,
poorly controlled hypertension
 Severe uncontrolled hypertension
on presentation (systolic >180 mmHg or
diastolic > 110 mmHg
 Ischaemic stroke > 3 months ago,
dementia or known intracranial
abnormality ( not covered in absolute
contraindications)
 Pregnancy
[2]
File 18 cardiovascular emergencies
If a patient’s only contraindication is hypertension please contact MO with a view to giving Tenecteplase. As
necessary discuss with coronary care unit.
Side effects
 Reperfusion cardiac arrhythmias, including ventricular fibrillation see Cardiac arrhythmias and have defibrillator ready
 bleeding Consult MO immediately
 hypotension
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Patients with severe pain require adequate analgesia. Intravenous is the preferred route of administration
for Morphine in people with chest pain. Consult MO and if not allergic give Morphine intravenously
If nauseated or vomiting, give Metoclopramide
MO may order GTN patch if patient has ongoing chest pain. Note: do not give GTN if has taken Viagra® in
the last 24 hours
Observe and monitor the patient closely in a suitably equipped room
Schedule
8
DTP
IHW / RIN / NP
Morphine Sulphate
Authorised Indigenous Health Workers must consult MO
Rural and Isolated Practice Endorsed Registered Nurses may proceed
Nurse Practitioners may proceed
Route of
Form
Strength
Recommended Dosage
Administration
Adults only: 2.5 mg
increments slowly, repeated
Ampoule
10 mg/mL
IV
every 10 min if required to a
maximum of 10 mg
Duration
Stat
Further doses should only be
given on MO’s orders to
achieve or maintain pain relief
Provide Consumer Medicine Information if available: Advise can cause nausea and vomiting, drowsiness
Management of Associated Emergency: Respiratory depression is rare. If it should occur give Naloxone as per Poisoning:
opiates HMP NB: as Naloxone counteracts the narcotic, it may cause the return of severe pain
Schedule
4
DTP
IHW / RIN / NP
Metoclopramide
Authorised Indigenous Health Workers must consult MO
Rural and Isolated Practice Endorsed Registered Nurses may proceed
Nurse Practitioners may proceed
Form
Strength
Route of Administration
Recommended Dosage
Duration
Stat. Further doses
Adults only: 10 mg
Ampoule
10 mg in 2 mL
IV
should only be given on
MO’s orders
Provide Consumer Medicine Information if available: not for use in patients with Parkinsons disease or children and caution
use in women less than 20 years of age.
Management of Associated Emergency: Dystonic reactions eg. Oculogyric crisis are extremely rare (unless repeated doses or
in children). If oculogyric crisis develops give Benztropine 2 mg IMI or IVI as per Mental health emergencies
Summary of management acute coronary syndrome
Cardiac enzyme (troponin) rises
ECG changes indicative of ischaemia
ie ST-elevation or new Left bundle branch block
Aspirin 300mg PO
Sublingual GTN
Tenecteplase (30-50mg)
Enoxaparin 1mg/kg S/C
Enoxaparin 30mg IV
Clopidogrel 300mg PO
Key: X means no /means yes
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Angina
X
X
MO MAY advise
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X
X
X
X
Non-STEMI
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X
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X
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X
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STEMI
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Complete rest in bed while awaiting evacuation / hospitalisation and observe for cardiac arrhythmias,
recurrence of chest pain, episodes of shortness of breath
Notify MO if pain recurs or abnormal cardiac rhythm
Give patient nil by mouth
5. Follow up:
 As directed by MO
 All patients given Tenecteplase should be under direct observation until evacuated
File 18 cardiovascular emergencies
 As the vessels re-open, the patient may have reperfusion arrhythmias eg VT and bradycardia. These
are generally managed conservatively (without drugs) as they are usually self limiting
6. Referral / Consultation:
 Consult MO on all occasions of chest pain
 May need transfer for coronary artery bypass surgery (CABG)