Chest Pain Flashcards
what is SBAR
- Situation - who are you and what the current situation
- background - when was the patient admitted, summarise the admission and the medical history
- assessment - what are the patients vital signs and what is your clinical impression
- recommendation - what kind of help do you require from me, after recording the full patient details on your job list you need a clear idea of the clinical situation of the patient - asked for the bedside observations and calculate a national early warning score (NEWS)
- used to describe key features when handing over a patient
What is NEWS used for
- can be used to quickly evaluate the urgency of a clinical situation, but its main aim is to trigger an early medical review of a clinical deteriorating patient
what might you think about when responding to a chest pain
- write down patient details and ward number
- location of the patient - need to know whether the review can wait until after I complete my outstanding jobs at the present location
- need to find information about the cause of chest pain
- If the patient look sick then priorities the review over outstanding jobs as patient is actually unwell
what should you ask on the phone to be performed to avoid any delays in deciding on management plan for the patient
- ask for an ECG to be performed so it is ready for when I arrive
What are common causes of chest pain
- Musculoskeletal: muscular, costochondritis
- Pulmonary: pulmonary embolism, effusion, pleuritis, pneumothorax
- Cardiac: angina, acute coronary syndrome, pericarditis, myocarditis, arrhythmia
- Vascular: aortic dissection
- Gastrointestinal: reflux, peptic ulcer disease, oesophageal spasm
describe the ABCDE that you follow in chest pain
- A (Airway): is the patient talking to you? If not, formally assess the patency of the airway
- B (Breathing): is the patient breathless? Check the oxygen saturations, record the respiratory rate and position of the trachea, and auscultate the chest
- C (Circulation): measure the radial and apical rate, blood pressure, capillary refill time, and auscultate the heart
- D (Disability): assess the conscious level and confirm the capillary blood glucose level
- E (Exposure): measure the patient’s core temperature and urine output (where appropriate), and complete a thorough examination where necessary, such as the abdomen
name key factors that it is important to establish early on in patient with chest pain
- What the ECG shows
- Whether the patient is still in pain
- Whether they are haemodynamically stable
- Whether there is any clinical evidence of heart failure
- Whether there have been any associated arrhythmias so far.
if a patient ECG shows ST segment elevation what should you do
f the patient’s ECG shows ST segment elevation, the immediate priority is to transfer them for coronary angiography and percutaneous coronary intervention
When is an ST elevation significant
- Greater than 2 mm in two contiguous chest leads, or
- Greater than 1 mm in two contiguous limb leads.
What does the term acute coronary syndrome encompass
- unstable angina
- ST segment elevation myocardial infarction (STEMI)
- NSTEMI
what are the NICE guidelines for a patient having an acute coronary syndrome
- carry out resuscitation if needed
- offer pain relief as soon as possible - may be with sublingual or buccal GTN or an intravenous opioid plus antiemetic
- BNF recommends giving a slow IV injection of morphine or diamorphine if an IV opiate is needed
- recommended metoclopramide (IV injection) as a suitable antiemetic provided there are no contraindications for example a GI obstruction, perforation, haemorrhage and recent GI surgery or phaeochromocytoma
- offer a single loading dose of 300mg aspirin as soon as possible if the patient is allergic to aspirin
- record a resting 12 lead ECG
- assess the patients oxygen saturation using pulse oximetry - offer oxygen to patients whose oxygen saturation is less than 94% and who have no risk of hypercapnia respiratory failure
Why do patients need continuous cardiac monitoring
- at risk of ventricular tachyarrhythmias, complete heart block and other bradyarrhythmias
How do you confirm a diagnosis of an NSTEMI
- confirm it through a rise in cardiac enzymes such as troponin
How often should you follow up with ECG patients who have NSTEMI
- do ECGs every 15-30 minute intervals
- this may indicate a change in the ECG suggestive of ischaemia or may indicate ongoing ischaemia
- patient has a need for immediate angiography as an emergency procedure
- may be subsequent evolution of changes on follow up ECGs for example T wave inversion
What is the immediate treatment for an NSTEMI
- Clopidogrel, prasugrel, or ticagrelor
- An anticoagulant (for example fondaparinux or unfractionated heparin).
