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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