Tony Cross CDU Low Risk ACS Proforma - V3.212 Review Due June 2014

7/23/2019 Tony Cross CDU Low Risk ACS Proforma - V3.212 Review Due June 2014

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O Erinfolami / S Dorrian

Patient Identification Label

Inclusion criteria for CDU

Cardiac sounding che

past 24 hours TIMI-RS score = 0 or Pain free on admissio Age > 18 yrs

TIMI-RS scoring (score 1 for ea

Criteria

Age > 65 yr

> 3 Coronary Artery Disease risk f

Prior stenosis > 50% (or previousST deviation on ECG> 2 angina events in < 24 hAspirin in last 7 d (regularly takenElevated cardiac markers

If unable to send patient to

--------------------------------------

Eme

LOW RISK PROB

Admitting Dr:

Patient reviewed by (M

anagement:

st pain, within

1 (see overleaf)n to CDU

Exclusion criteria:

Ongoing chest

Irrespective of• Known IHD

• Acute ECG chachanges or arrh

• Elevated cardia Suspected or p

of chest pain CCF Haemo-dynami Co-morbidity or

hospital admiss Unclear history No reliable cont

telephone

TIMI-RS SCORINGh risk)

actors (FH, Elevated cholesterol, HT, DM, Active

cute Myocardial Infarction or revascularisation)

on physicians’ advice)

TOTAL TIMI SCORE (0 OR 1 ONL

DU please document why (e.g. no spac

------------------------------------------------------

rgency Department

Tony Cross CDUBLE ACS PROFORMA

/Consultant):

ain

IMI-RS score

nges (ST/T waveythmias)

c enzymesoven alternative cause

instabilitysocial reason requiring

ion

act address and

Present?(tick)

smoker)

FOR CDU) /7

, patient too ill etc…):

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Summary of Low risk probable ACS Management Guideline

Management in ED History & examination – clinical suspicion of ACSECG baseline & further ECG after 1 hour (or prior to transfer)Aspirin 300mg po stat (if no C/I)Bloods – Lipids, FBC, U/E, Glucose, Troponin

Management in CDU

Observations &nursing care:

Full set observations,MEWS & ECG 4hrly

Medications:

Commence on statin if cholesterol > 5mmol/L: Simvastatin 20mg po nocte

Refer to cardiology or RMO if chest pain, ECG changes or elevated cTnT (at any point)

Timing of review 2n

Troponin to be taken as per hospital guidelines;

If initial sample normal, repeat in 6 hours

If initial sample raised, repeat in 3 hours AND refer to RMO

Review at 8 hours OR once 2nd

Troponin result available

Criteria foradmission(at any time or afterfinal review)

Social circumstances prevent discharge Haemodynamically unstable patient (BP >180 or <100, Pulse <50 or >100) Further episode chest pain Abnormal ECG Positive Troponin T

After final review:Criteria fordischarge +

Discharge Plan

Criteria for discharge:

No chest pain whilst in CDU

No ECG abnormalities

Negative Troponin T (at baseline and 6hrs after the last episode of pain)

Patient able to come back if they develop chest pain (If not, refer for in-patientreview). ADVICE TO RETURN IMMEDIATELY IF PAIN RETURNS

Discharge Plan:NICE IHD Risk <10% NICE IHD Risk 10 – 60% NICE IHD Risk >61%

No follow up No medication

Book patient aCoronary CT – see

below Meds - Aspirin 75mg

daily, GTN Spray,Statin if indicated

Refer to CardiologyOP

Meds - Aspirin 75mgdaily, GTN Spray,Statin if indicated

ALL PATIENTS: Appropriate patient and GP letters




Time Flow of patients on CDU Chest Pain pathway

T r o p o n i n t i m e s

• Time initial

• Time ifabnormal

• Time ifnormal

• Estimatedtime ofpathwaycomplete

G u i d e l i n e

s o n w h e n t o t a k e T n T

• BaselineTnT

• Initial TnTnormal?repeat at6hrs

• Initial TnTraised?

Refer toMed!ardiolo"y#repeat at$hrs if stillin E%&

E ! G t i m e s

• E!G ' ( )

E%shopfloor

• E!G $ at*hrs postarri+al E%

• E!G * at ,

hrs postarri+al E%

Criteria for admission & referral to RMO/Cardiology: (EXIT PATHWAY

TO CPAU/RESUS/MAJORS AS REQUIRED):

Unstable medical condition

Further Chest pain episode

Abnormal ECG

Abnormal Troponin




NICE definition ofangina pain

NICE defines angina as:

• Constricting pain at the front of the chest, arms, shoulders or jaw

• Precipitated by physical exertion

• Relieved by rest or GTN in about 5 minutes

All of the above = typical angina, two of the above = atypical angina, one or none ofthe above = non-anginal chest pain

NICE Riskstratification forCoronary CT Request& Disposal:

How to Assess the likelihood of CAD

EXCLUSION OFCORONARYARTERY DISEASE(CAD):

ACS is excluded following serial normal ECG’s and 2 negative Troponin, with one atleast 6 hours after chest pain episode.

EXCLUSION OF ACS DOES NOT MEAN THE PATIENT DOES NOT HAVECORONARY ARTERY DISEASE – CONTINUE ON THE PATHWAY FOR FURTHER

INVESTIGATION AND MANAGEMENT AS AN OUTPATIENT

Coronary CT**:

Inclusion criteria Exclusion criteria

10 – 60% CAD risk on NICE guideline <10% CAD risk on NICE guideline: No

follow upNormal ECG & Negative Troponin >61% CAD risk on NICE guideline: refer

to Cardiology OP (see ED Intranet)No known CAD Known CADAge: <70yrs, males >30, females >35 yr e-GFR <40BMI <38 Severe Asthma/aortic stenosis/LVF

Book CCTA via iCare, fill in cardiac CT pilot request form and follow flow chart of care

Tony Cross CDU Low Risk ACS Proforma - V3.212 Review Due June 2014

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