Sam speaks to Dr Adele Pope, advanced cardiology trainee at Auckland Hospital, about how to attack the most common, and often the most uncertain, ward call.
* Life threatening
* Cardiac tamponade
* Oesophageal bleed
* Mechanical (foreign body, surgical, chest drain, post-pleurocentesis)
* Oesophageal spasm
* Rib fracture
* Below the chest
* Upper abdominal pain
* Above the chest
* Eyeball the patient
* Calling a code
* 777 (or your local hospital emergency number)
* This is Sam, medical house officer. I need the adult resus team to attend North Shore Hospital, ward 10, room E3.
* SOCRATES (site, onset, character, radiation, associated symptoms, timing, exacerbating factors, severity)
* Previous similar episodes? History of exertion chest pain?
* Shortness of breath
* Review of systems
* Identify risk factors
* Vitals + Examination
* General inspection + peripheries
* Aiming to identify red flags of hypotension, reproducibility on palpation and respiratory issues
* Abdomen, calves, catheter and drains (for completeness)
* Take your time and be systematic
* Look at an old ECG
* Ischaemic ECG defined as STEMI, or any T wave inversion, ST depression, Q waves.
* Look for contiguous and reciprocal abnormalities.
* T wave change normal variants occur in III, aVR, V1.
* A repeat ECG in 15 minutes is useful to identify dynamic changes.
* Consider investigations
* FBC, U&E, troponin
* CXR if failure or respiratory issues are within your differential (not so useful for ACS, but unlikely to harm)
* Call for help (code or at least registrar support)
* Attach continuous monitoring e.g. defibrillator pads
* Re-assess stability of the patient
* Oxygen only if hypoxic
* GTN spray
* Opiate analgesia (IV morphine boluses ideally)
* Determine bleeding risk
* Identify any anti-platelet and anti-coagulation medicines in use
* Post-operative status
* Consider loading with aspirin 300 mg PO
* Review past notes
* Basics (date/time/name/reason for review)
* Positives and pertinent negatives
* Impression and differential with justification. Have you eliminated life threatening conditions?
* Consider TIMI or HEART score (acknowledging use outside of ED)
* Clear and specific plan
* Consider discussion with senior and escalation, especially if called back to patient again
Specificity of chest pain symptoms and examination findings [Evidence]
Fanaroff AC, Rymer JA, Goldstein SA, Simel DL, Newby LK. Does This Patient With Chest Pain Have Acute Coronary Syndrome?The Rational Clinical Examination Systematic Review. JAMA. 2015;314(18):1955–1965. doi:10.1001/jama.2015.12735
* No single finding rules in or rules out acute coronary syndrome.
* The most specific (convincing) symptoms of ACS were:
* Pain radiation to both arms (specificity, 96%; LR, 2.6 [95% CI, 1.8-3.7]).