Scribd Logo
Upload

Welcome to Scribd!

  • Protocol 13: Chest Pain: A&E Doctor

    Uploaded by

    Vanessa Hermione
    53 views4 pages
    This document provides guidelines for evaluating and managing patients presenting with chest pain. It outlines the TIMI risk score used to assess risk of acute coronary syndrome. For low-intermediate risk patients with chest pain where ACS needs to be ruled out, the protocol describes criteria for exclusion from the chest pain protocol and interventions in the short stay unit including monitoring and testing. It provides discharge criteria and recommendations for follow up stress testing or cardiac CT angiography and cardiology referral depending on risk factors.

    Original Description:

    Original Title

    ChestPain_Oct2016_v3

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document provides guidelines for evaluating and managing patients presenting with chest pain. It outlines the TIMI risk score used to assess risk of acute coronary syndrome. For low-intermediate risk patients with chest pain where ACS needs to be ruled out, the protocol describes criteria for exclusion from the chest pain protocol and interventions in the short stay unit including monitoring and testing. It provides discharge criteria and recommendations for follow up stress testing or cardiac CT angiography and cardiology referral depending on risk factors.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    53 views4 pages

    Protocol 13: Chest Pain: A&E Doctor

    Uploaded by

    Vanessa Hermione
    This document provides guidelines for evaluating and managing patients presenting with chest pain. It outlines the TIMI risk score used to assess risk of acute coronary syndrome. For low-intermediate risk patients with chest pain where ACS needs to be ruled out, the protocol describes criteria for exclusion from the chest pain protocol and interventions in the short stay unit including monitoring and testing. It provides discharge criteria and recommendations for follow up stress testing or cardiac CT angiography and cardiology referral depending on risk factors.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    of 4

    Paste patient’s sticky label here.

    PROTOCOL 13: CHEST PAIN


    A&E DOCTOR

    TIMI Risk Score for UA/ NSTEMI


    Characteristics scoring 1 point each :
     Age ≥ 65
     ≥ 3 risk factors for CAD (includes family hx of CAD, HPT,
    hypercholesterolemia, DM, current smoker)
     Known CAD (stenosis ≥ 50%)
     Aspirin use in past 7 days
     Severe angina symptoms (e.g. ≥ 2 angina events in last 24 hrs.)
     ST deviation ≥ 0.5 mm on ECG
     Elevated serum cardiac markers

    Inclusion Criteria:

     Low to intermediate risk chest pain, where acute coronary syndrome needs to be ruled
    out
     TIMI score 2 or less
     No ischemic changes on ECG and first Troponin normal (< 30 ng/L)
     No dynamic changes on serial ECGs

    Exclusion Criteria
     Chest pain which occurred more than 2 hours prior to A&E consultation
     Typical angina or exertional symptoms
     TIMI score 3 or more
     Evidence of STEMI via ECG or NSTEMI via markers (Troponin ≥ 30ng/L)
     Haemodynamic instability (including acute cardiac failure)
     Cardiac arrhythmias
     Toxicological cause of chest pain (e.g. amphetamines, cocaine etc.)
     Clinical suspicion of aortic dissection, PE, or pulmonary cause
     Clear cut musculoskeletal or non-cardiac chest pain
     Multi system dysfunction requiring in-patient management
     ESRF and chronic renal failure patients
     Patients with Systemic Lupus Erythematosus

    DOCTOR’S NAME

    Updated Oct 2016 V3 Page 1


    Paste patient’s sticky label here.

    SSU DOCTOR

    SSU Interventions

     Vital signs and pain score hourly x 2, then 2 hourly x 2, subsequently 4 hourly
     Chest X-Ray (if not done already)
     Cardiac monitoring x 6 hrs. for arrhythmias
     ECG at 3 and 6 hrs. post SSU admission
     Troponin at 3 and 6 hrs. post SSU admission
     ECG and Dr review whenever an episode of acute chest pain occurs

    Discharge Criteria
     Resolution of symptoms
     No ECG changes or Troponin rise

    On Discharge

     All patients need cardiology follow up


     If first episode of chest pain and needs risk stratification, consider:
    o Stress test (treadmill) - same day or within 48 hrs. of discharge
    o If not suitable for treadmill and age < 65:
     Coronary CT Angiography (CCTA) same day or within 48 hrs. of
    discharge
    (See Appendix B for contraindications and steps in ordering)

    o If not suitable for treadmill and age > 65:


     Obtain early Cardiology appointment for further work-up

     All patients to be discharged with advice letter shown below (Appendix A)


     Consider starting aspirin, after assessing bleeding risk, unless clearly atypical.

    Admission Criteria
     Persistent or worsening symptoms (chest pain or SOB) while in SSU
     Hypotension or arrhythmia in SSU
     ECG changes
     Troponin rise

    DOCTOR’S NAME

    Updated Oct 2016 V3 Page 2


    Paste patient’s sticky label here.

    Appendix A - Chest Pain Discharge Advice

    There are many different causes for chest pain, including heart or lung disease, chest muscle strain, broken ribs,
    pinched nerves and heartburn. Chest pain can also be transferred from another part of the body. This is called
    referred pain.

    The doctor has run some tests to determine your chest pain is not caused by a heart attack. However there still may
    be underlying coronary artery disease, and further tests are needed to check for this. Hence it is important for you to
    come back for your follow-up tests and Cardiology appointment. Also, be aware of the signs of a heart attack, and
    seek medical help immediately if you should experience any of them.

    Heart Attack: Early Warning Signs

    Heart attacks occur when there is a sudden, complete blockage of blood flow to part of the heart muscle. Early
    treatment is crucial for heart attack victims. Quick treatment to break up blood clots can greatly improve a person's
    chance of surviving a heart attack. Since early treatment makes a difference, it is important to know the early signs of
    a heart attack. Not everyone has the same symptoms. Signs of a heart attack may be one or more of the following:

     You have chest pain that is crushing or squeezing or feels like a heavy weight on the chest
     Sweating
     Paleness or a grey colour to your skin
     Shortness of breath (difficulty catching your breath)
     Nausea (sick to your stomach) or vomiting (throwing up)
     Pain spreading from the chest to the back, neck, jaw, upper abdomen (belly) or one or both shoulders or
    arms
     Dizziness or light-headedness (feel like you are going to faint)
     A fast, slow or irregular heartbeat
     Indigestion-like pain in the chest, especially if worse with activity
     Unexplained anxiety, weakness or fatigue
     Women who are having a heart attack may not have the usual symptoms, resulting in a delay in care. About
    a third of women have no chest pain at all when having a heart attack.

    What should I do in case of a heart attack?

    If you or someone you know feels chest discomfort, especially with one or more of the other symptoms:
     Get medical care immediately.
     Do not wait longer than 5 minutes before calling 995. Calling 995 is usually the fastest way to get medical
    help in an emergency.

    If you think a person is having a heart attack:


     Call 995 for emergency help. Stay on the line. Do not take the person to a hospital in your own car.
     Be calm and take actions that make the victim feel less excited.
     Have the victim sit or lie down.
     Ask the person if they take any medicines for chest pain, such as nitro-glycerine. If so, get it and follow the
    written instructions on its use.
     Ask the person if they are allergic to aspirin. If they are not allergic, have them chew an aspirin as soon after
    calling 995 as possible.
     If the person stops breathing, begin CPR. Tell the 995 operator that this has happened.

    For more information about giving CPR and other life-saving skills, contact: Changi General Hospital at 6788 8833

    DOCTOR’S NAME

    Updated Oct 2016 V3 Page 3


    Paste patient’s sticky label here.

    Appendix B - Guideline for Coronary CT Angiography

    Contraindications to CCTA:
    ● Arrhythmias
    ● Hx of CAD
    ● Allergy to contrast
    ● Renal failure
    ● Contraindications to beta blockage or GTN
    ● Obesity
    ● Caution in ordering this for young patients, especially young females
    ● CCTA not recommended for patients > 65 years old. Please refer Cardiology early for further work-
    up.

    How to order CCTA after SSU discharge:

    ● Print out CPOE form (stating “SSU Chest Pain Protocol” under Special Instructions/Comments
    section)
    ● Document time of last meal, hx of asthma, DM on metformin, latest Creatinine, and hx of previous
    stent/bypass (under clinical history)
    ● Call extension 1928 to inform A&E CT radiographer to book appointment for patient, and do patient
    education.
    ● Book Cardiology SOC follow-up appointment at Counter 18 in A&E

    Abnormal CCTA Results:

    Critical Stenosis Moderate Stenosis Mild Stenosis If mild stenosis,


    (≥ 70%), Left Main (50 – 70%), or (< 50%) normal, or
    stenosis ≥ 50%, anomalous equivocal report,
    or other sig. coronaries but Ca score >
    thoracic 100
    diagnosis

    - Abnormal report will - Abnormal report - Abnormal report will


    be sent to A&E via will be sent to A&E be sent to A&E via
    email via email email
    - Radiologist will call
    Con2 to inform of
    - Con1 to ensure - Con1 to ensure - Con1 to ensure
    critical result
    patient on aspirin and patient on aspirin patient on aspirin and
    call Cardio to force in call Cardio to force in
    - Con2 to recall
    appointment within 1 - No need for early appointment within 1
    patient for admission
    week Cardio TCU week

    DOCTOR’S NAME

    Updated Oct 2016 V3 Page 4

    You might also like