Download integrated care pathway for suspected acute coronary syndrome (acs)

Patient identification label
INTEGRATED CARE PATHWAY FOR
SUSPECTED ACUTE CORONARY
SYNDROME (ACS)
Date:
Location:
Time:
Admitting Consultant:
Name of next of kin:
Relationship:
Contact details:
Drug Allergies and Sensitivities:
Initial assessment: Check if the pain is cardiac and consider the following:
History of the pain
YES
NO
1) Constricting discomfort in the chest, neck, arm, back or jaw lasting longer than 15 minutes
2) Chest pain with nausea and vomiting, marked sweating or breathlessness (or a combination
of these), or with haemodynamic instability. Chest pain may not be the main symptom.
3) New onset chest pain or abrupt deterioration in stable angina, with recurrent pain occurring
frequently with little or no exertion and often lasting longer than 15 minutes?
IS ACS the most likely diagnosis?
NO
DO NOT USE THIS PATHWAY
YES
Record a 12 lead ECG. Are there any of the
following features?
1. ST elevation in 2 contiguous leads, 1mm
in limb leads or 1mm in chest leads
2. Acute ECG changes consistent with
posterior STEMI (ST depression in V1 to
V4 inclusive)
3. New onset LBBB with good history of
STEMI
Approved date: July 2013
Review date: July 2016
YES
NO
Page 1 of 8
Follow the A&E PPCI pathway and
DO NOT USE THIS PATHWAY. If
they are deemed unfit for PPCI
following discussions with RD+E then
you may USE THIS PATHWAY.
USE THIS PATHWAY
Lead: Christopher Gibbs
Version: 1
Northern Devon Healthcare NHS Trust
Incorporating community services in Exeter, East and Mid Devon
Patient identification label
Date:
Time:
Name:
Title:
History of presenting complaint:
Associated symptoms
YES
Dyspnoea
Nausea and/or vomiting
Sweating
Presyncope
Syncope
Palpitations
Paroxysmal nocturnal
dyspnoea
Orthopnoea
NO
Coronary risk factors
YES
NO
Hypertension or on antihypertensives
Hyperlipidaemia or on lipid lowering agents
Smoking/exsmoker
Previous history of angina
Previous history of myocardial infarction
Ischaemic heart disease in first degree
relatives <55 years of age
Diabetes (circle as
Diet
No
appropriate)
controlled
Tablet
controlled
Insulin
controlled
Previous ischaemic heart disease or cardiac investigations:
Other past medical history:
Approved date: July 2013
Review date: July 2016
Page 2 of 8
Lead: Christopher Gibbs
Version: 1
Northern Devon Healthcare NHS Trust
Incorporating community services in Exeter, East and Mid Devon
Patient identification label
System enquiry:
Drug history
Medication on Admission
Dose
Route
Frequency
Hold and
review
Stop
Confirmed
Information sources (tick all boxes that apply when taking history (Hx) and on subsequent confirmation (conf).
Confirmation of medication should be made within 24 hours of admission where possible by pharmacy staff
Hx
Conf
Hx
Conf
Patient/Carer
GP letter
GP surgery contacted
Nursing home records
Repeat prescription
Previous TTA/chart dated (current TTA
for community hospital transfers)
GP printout
Unable to obtain medication/history
Other (specify):
Brought medicines from home
History taken by:
Designation:
Date:
Bleep:
Confirmed by:
Designation:
Date:
Bleep:
Approved date: July 2013
Review date: July 2016
Page 3 of 8
Lead: Christopher Gibbs
Version: 1
Northern Devon Healthcare NHS Trust
Incorporating community services in Exeter, East and Mid Devon
Patient identification label
Family history:
Is there any family history of sudden cardiac death?
Social history:
Activities
Smoking
Driving
Occupation
Alcohol
Cognitive function
Functional ability
Examination:
Pulse:
BP:
Sats:
Other:
RR:
Temp:
BM:
GCS:
General comments:
Cardiovascular
Respiratory
JVP:
Oedema:
Heart sounds:
Abdominal
Approved date: July 2013
Review date: July 2016
Other
Page 4 of 8
Lead: Christopher Gibbs
Version: 1
Northern Devon Healthcare NHS Trust
Incorporating community services in Exeter, East and Mid Devon
Patient identification label
Initial investigations:
1. CXR and comments:
2. ECG and comment:
3. Bloods – FBC, U+E, LFT, Trop T, INR, and lipids
Date
Time
Hb (11.5-18)
MCV (80-100)
WCC (4-11)
Neuts (2-7.5)
Plt (150-400)
INR
Na (135-145)
K (3.5-5.2)
Urea (2.5-7.5)
Creat (50-100)
Corr Ca (2.20-2.60)
PO4 (0.8-1.5)
ALT (3-36)
ALP (<124)
Bili (<26)
Alb (35-50)
CRP (<8)
1. ST elevation (or presumed LBBB in
context of symptoms) – call RD&E if
patient deemed appropriate for PPCI
2. Normal – does not exclude ACS
3. Non specific/non diagnostic changes,
consider other life threatening
causes such as PE/dissection
Date
Time
Trop T
Cholesterol (<5.2)
Glucose
HbA1c
Mg (0.7-1)
ABG results
Working diagnosis:
Approved date: July 2013
Review date: July 2016
Page 5 of 8
Lead: Christopher Gibbs
Version: 1
Northern Devon Healthcare NHS Trust
Incorporating community services in Exeter, East and Mid Devon
Patient identification label
Initial Management
1. Analgesia (GTN spray, morphine plus antiemetic)
2. BP and Pulse Oximetry monitoring – ONLY give O2 to
maintain SaO2 >94% or to maintain SaO2 88-92% in
those at risk of hypercapnoeic respiratory failure
3. Aspirin 300mg if not had already by ambulance team
Do they have any features that would increase bleeding risk such as advancing age, previous
bleeding complications, renal impairment or low body weight?
No
YES
Give:
1. Start enoxaparin at 1mg/kg/BD (unless on
warfarin). Give half dose if eGFR <30ml/min
2. Consider lansoprazole 30mg if concerns about
bleeding
Treat pulmonary oedema with furosemide 40mg IV (consider 2nd dose if no response after 20
minutes, isosorbide dinitrate infusion (titrate to BP>100 systolic), morphine 5mg IV with
antiemetic and CPAP
Refer to medics and if any concerns discuss with the medical registrar
Approved date: July 2013
Review date: July 2016
Page 6 of 8
Lead: Christopher Gibbs
Version: 1
Northern Devon Healthcare NHS Trust
Incorporating community services in Exeter, East and Mid Devon
Patient identification label
Under medical team:
Activities
Signature of doctor checking
ECG at 1 hour
ECG at 6 hours
ECG at 24 hours
3 hour Trop T
9 hour Trop T
Write drug chart
Check history, bloods, ECG in A+E and CXR
Post Take Round (or Senior Review if being discharged)
Date:
Time:
Consultant or SPR:
Review of Hx:
Communication:
Final Diagnosis (please circle):
NOT ACS
PROBABLE ISCHAEMIC
CHEST PAIN
TROP T NEGATIVE ACS
(UNSTABLE ANGINA)
TROP T POSITIVE
ACS (NSTEMI)
TROP T POSITIVE
ACS (STEMI)
Additional Diagnoses:
Approved date: July 2013
Review date: July 2016
Page 7 of 8
Lead: Christopher Gibbs
Version: 1
Northern Devon Healthcare NHS Trust
Incorporating community services in Exeter, East and Mid Devon
Patient identification label
Plan:
Ensure patient is on following medications (unless contraindicated)
Yes
No
If not given state why
Aspirin 75mg OD
Beta blocker
ACE inhibitor
Statin
Enoxaparin if started on admission for 48 hours then stop
Calculate the GRACE score. NOTE you only need to calculate the 6 month mortality percentage:
GRACE score: ……………………………….
If GRACE score >1.5% and no bleeding risk (advancing age, previous bleeding complications, renal
impairment, or low body weight) give 300mg clopidogrel and continue at 75mg OD. (tick box if done)
If not given, please state why below:
Are any of the following present?
1. GRACE score >3%
2. Recurrent chest pain during admission
No
Discharge patient and white top referral for
Cardiologists to pick up when they do their
MAU round (tick box if done)
3. Raised Trop T with no other explanation
YES
1. Inpatient referral to Cardiology (tick box if requested)
2. If NSTEMI, obtain an ECHO to assess LV function (tick box if requested)
3. Uptitrate meds ACE and BB if appropriate (tick box if done)
Approved date: July 2013
Review date: July 2016
Page 8 of 8
Lead: Christopher Gibbs
Version: 1