Adult Chest Pain Protocol
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ADULT CHEST PAIN PROTOCOL History - Triage ? Character of Pain – Left sided, Radiating to shoulder, arm, neck, lower jaw or back. ? Chest pain for past 20 min not relieved by rest/nitrates. ?Prior History of CAD ?Risk factors Management: Within 1 st 10 min – Focussed History, Associated symptoms, inform Cardiologist / Intensivist. 12 lead ECG. If IWMI is suspected take additional ECGs with V7, V8, V9 for PWMI, V3R, V4R for RVMI. Connect to Cardiac Monitor/ Defibrillator Collect samples for cardiac enzymes MONA Therapy – Inj. Morphine for severe pain (Ask for h/o wheezing) 2-4mg stat + 2-4mg as required every 15 minutes Oxygen to increase SpO2 > 95% (2-4L by nasal prongs / mask) T.Sorbitrate 5mg SL stat / GTN spray 1 puff SL T.Aspirin 300mg + T.Clopidogrel 300mg PO chewed stat IV Access with 18G cannula in both hands. IVF NS 250 ml slow fluid challenge if suspicion of IWMI/RVMI/PWMI
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Transcript of Adult Chest Pain Protocol
ADULT CHEST PAIN PROTOCOL
History - Triage
? Character of Pain – Left sided, Radiating to shoulder, arm, neck, lower jaw or back.
? Chest pain for past 20 min not relieved by rest/nitrates.
?Prior History of CAD
?Risk factors
Management:
Within 1st 10 min – Focussed History, Associated symptoms, inform Cardiologist / Intensivist.
12 lead ECG. If IWMI is suspected take additional ECGs with V7, V8, V9 for PWMI, V3R, V4R for RVMI.
Connect to Cardiac Monitor/ Defibrillator
Collect samples for cardiac enzymes
MONA Therapy – Inj. Morphine for severe pain (Ask for h/o wheezing)
2-4mg stat + 2-4mg as required every 15 minutes
Oxygen to increase SpO2 > 95% (2-4L by nasal prongs / mask)
T.Sorbitrate 5mg SL stat / GTN spray 1 puff SL
T.Aspirin 300mg + T.Clopidogrel 300mg PO chewed stat
IV Access with 18G cannula in both hands.
IVF NS 250 ml slow fluid challenge if suspicion of IWMI/RVMI/PWMI
Next 10 minutes – If ECG diagnostic of MI – ST Elevation in 2 or more contiguous leads or New onset LBBB then discuss about PCI / Thrombolysis.
Biomarkers - Troponin T to be sent - do not wait for result. Used as confirmatory test for diagnosis. If negative initially, repeat measurement after 12 hours is recommended.
Ask for contraindications to thrombolysis.
Door to Thrombolysis time – 30 min.
Thrombolysis:
Inj Streptokinase 1,500,000Units in 100ml NS over 45min
Watch for hypotension/crepts. Decrease Stretokinase infusion rate if hypotension occurs. Use small 150 ml fluid challenge initially & start Inj.Dopamine at 10mics/kg/min & titrate if BP is persistently low or crepts are auscultated.
Repeat ECG 1 hour after thrombolysis.
Other Interventions to be considered in case of dx of Unstable angina (UA)/Non-STEMI (NSTEMI).
Low-molecular-weight heparin (LMWH)
Glycoprotein (GP) IIb/IIIa Inhibitors - Tirofiban
Other beneficial therapies to be started within 24 hours
Beta Blockers - Metoprolol
Angiotensin-Converting Enzyme (ACE) Inhibitors
HMG CoA (3-Hydroxy-3-Methylglutaryl-Coenzyme A) Reductase Inhibitors (Statins)
