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Presentation on Chest
Pain ManagementRanju Shrestha
3rd Year, Student No: 220118916
HSNS368: Professional Practice: Contexts of Critical Care
2016
Outline
• Overview
• Statistics
• Assessment
• NSW Chest Pain Pathway
• Management
• Summary
2
Overview
• Chest pain is a hallmark symptom for the diagnosis of Acute Myocardial Infarction(AMI) or heart attack.
• AMI is a life-threatening condition occurring when there is sudden blockage in the bloodsupplying to itself leading to the damage of the heart muscle and eventually alters itsfunction (Heart Foundation, 2016).
• It is medical emergency and categorized as code Blue.
• An immediate clinical management is necessary, so it falls under Australian triagecategory 2 and treated with high priority (clinical care is to be initiated within 10minutes) (Pallas, 2014).
• Location: central chest radiating to neck, jaw, shoulder and left arm
3
Statistics
• According to the overall result from more than 190 countries reveals that the heartdisease is number one global cause for death with 17.3 million deaths every year(American Heart Association, 2015).
• There is significantly higher incidence of heart disease in the western society (Pallas,2014).
• In Australia, the estimation of over 350,000 people had heart attack at some stages oftheir lives. More than 100,000 Australians are reported to have heart attack under 65years of age. In 2012/13, 54,000 hospitalizations were due to heart attack which iselevated by 15% from 2003/2004. In addition, the deaths from heart attack accounted8,611 in 2013, in general, 24 deaths every day (Heart Foundation, 2016).
4
Assessment
Initial Assessment
• Full set of vital signs (HR, BP, RR, O2Sats, Temp)
• Baseline neurological assessment (GCS)
• Brief patient history (presenting s/s, medical history, current medications andallergies, risk factors like HTN, obesity, high cholesterol)
• Brief physical examination (Look, Listen and Feel)
• Pain assessment (PQRST)
(Pallas, 2014)
5
NSW Chest Pain Pathway
Uniform guide for any patient with
chest pain presenting to NSW
hospitals
2 versions dependent on PCI
capability with (John Hunter) and
without (Maitland, Belmont, Mater)
(NSW Health, 2011)
6
STEMI
(Jaturawutthichai, 2016)
7
General Management
Cardiac monitoring (Telemetry)
Troponin (myocardial damage, detected in blood stream even after 2-4 hours of myocardialinjury), normal level <0.01ng/ml but in chest pain its >/=0.01 ng/ml detecting cardiac injury(Martinez, & Bucher, 2014)
ECG
• Most important diagnostic tool for chest pain
• ST elevation (inflammation), pathological Q wave (myocardial necrosis), T wave inversion(acute ischemia), left bundle branch block
Routine blood tests
• FBC, EUC, LFT
(Pallas, 2014)8
General Management
Oxygen therapy
• Although supplemental oxygen is recommended practice for years, the supporting evidence isinconsistent.
• Recent evidence reflects associated risk of hyper-oxygenation of ACS patient with normaloxygen saturation can outweigh potential benefit
• The Australian Resuscitation Council in 2011 recommends oxygen to be used for managingbreathlessness/ hypoxia instead of routine treatment of chest pain (Pallas, 2014).
β-adrenergic blockers
• Decrease myocardial demand by the reduction of HR, BP and contractility
• Use in first hours is evident to reduce infarction size and incidence of complication
(Gallagher, & Driscoll, 2012)9
General Management
IV access (2 IV lines)
• Rapid administration of medications
• Venous blood gas (respiratory distress/ palpitations)
Chest X-ray
• Physical abnormalities, pulmonary oedema, pneumonia, pneumothorax, rib fracture
Pain relief
• Glyceryl trinitrate (GTN) (dilates coronary blood vessels), 300-600 mcg sublingual GTN
• Narcotics (Morphine) (vasodilators)
(Pallas, 2014)
10
Thrombolytic and Reperfusion
Anti-thrombotic drug
• Aspirin, single dose of 300 mg in ED
Reperfusion therapy
• Tenecteplase, Reteplase (tissue type plasminogen activators)
• Activates plasminogen presented in blood clots, so the risk of haemorrhage is minimized
(Pallas, 2014)
11
Summary
• Chest pain in a medical emergency
• Early management is essential for preserving life
• Brief assessment is required to underline predisposing factors
• NSW chest pain pathway is guided to plan the management actions
• Regular monitoring of the patient is essential
12
References
• American Heart Association. (2015). American Heart Association statistical report tracks global figures for first time.
Retrieved from http://news.heart.org/american-heart-association-statistical-report-tracks-global-figures-first-time/
• Gallagher, R. & Driscoll, A. (2012). Cardiovascular alterations and management. In D. Elliott, L. Aitken, & W.
Chaboyer (Eds), ACCCN's Critical Care Nursing. Elsevier Australia. Retrieved from https://www-elsevier-elibrary-com
• Heart Foundation. (2016). Heart attack fact sheet. Retrieved from http://heartfoundation.org.au/about-us/what-we-
do/heart-disease-in-australia/heart-attack-fact-sheet
• Jaturawutthichai, P. (2016). ECG of ST elevation myocardial infarction ( STEMI ) and detail of ECG ( P wave , PR
segment , PR interval , QRS complex , QT interval , ST elevate , T wave ) Acute coronary syndrome , angina pectoris.
Retrieved from http://www.shutterstock.com/pic-403308256/stock-vector-ecg-of-st-elevation-myocardial-infarction-
stemi-and-detail-of-ecg-p-wave-pr-segment-pr.html
• Martinez, L. G. & Bucher, L. Adapted by Gallagher, R. (2014). Nursing Management: coronary artery disease and acute
coronary syndrome. In D. Brown & H. Edwards (Eds), Lewis's Medical-Surgical Nursing: Assessment and Management
of Clinical Problems. Elsevier, Australia. Retrieved from https://www-elsevier-elibrary-com13
NSW Health. (2011). Chest Pain Evaluation (NSW Chest Pain Pathway).
Retrieved from
http://www0.health.nsw.gov.au/policies/pd/2011/pdf/pd2011_037.pdf
Pallas, J. (2014). Managing chest pain in emergency department: A resource for
emergency nurses. Retrieved from
http://intranet.hne.health.nsw.gov.au/__data/assets/pdf_file/0017/142163/Managi
ng_chest_pain_package_2014.pdf