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Chest Pain (includes Noncardiac) - Adult

Sep.11.2020

Chest Pain (includes Noncardiac) (Adult ED)

Clinical Description

  • Care of the Emergency Department patient seeking treatment for chest discomfort or pain.

Key Information

  • Goal is “Door to ECG (electrocardiogram)” time less than or equal to 10 minutes.
  • Severity of chest pain has little association with seriousness of the cause.
  • Use of a risk stratification tool is recommended to accelerate diagnosis of life-threatening causes of chest pain.
  • Timely treatment must be initiated when cardiac cause is identified.
  • If myocardial infarction is suspected, aspirin should be given orally, unless contraindicated.
  • Women may have atypical symptoms of cardiac ischemia that may include fatigue, shortness of breath without chest pain, nausea, vomiting, back or jaw pain, dizziness and weakness.
  • Avoid nitrates if patient has taken phosphodiesterase inhibitor (for erectile dysfunction) in past 24 hours or in the presence of hypotension.

Threats to Life, Limb or Function

  • acute coronary syndrome
  • cardiac tamponade
  • cocaine toxicity
  • life-threatening dysrhythmia
  • pulmonary embolism
  • tension pneumothorax
  • vascular dissection

Clinical Goals

By transition of care

A. The patient will achieve the following goals:
  • Goal: Acute Signs/Symptoms are Managed

  • Goal: Acceptable Pain Level Achieved

    Correlate Health Status

    • Correlate health status to:

      • history, comorbidity
      • age, developmental level
      • sex, gender identity
      • baseline assessment data
      • physiologic status
      • response to medication and interventions
      • psychosocial status, social determinants of health
      • barriers to accessing care and services
      • health literacy
      • cultural and spiritual preferences
      • safety risks
      • family interaction
      • plan for transition of care

    Chest Pain

    Associated Documentation

    • Chest Pain Management

    Presentation

    • chest discomfort described as heaviness, aching, burning, choking, squeezing
    • discomfort (pain) may be substernal, radiate down arms and back and up to jaw
    • pain that follows a dermal pattern; localized and easy to describe
    • poorly localized pain in chest

    Associated Signs/Symptoms

    • abdominal bloating
    • abdominal discomfort
    • blood pressure variable
    • cough
    • cyanosis
    • diaphoresis
    • edema
    • fatigue
    • fluid status
    • heart rate variable
    • indigestion
    • nausea and vomiting
    • orthopnea
    • pallor
    • palpations
    • peripheral pulses diminished
    • sense of impending doom
    • shortness of breath
    • syncope
    • weakness

    Potential Causes

    • acute aortic syndrome, such as aortic dissection or intramural hematoma
    • acute coronary syndrome
    • emotional or psychological condition, such as stress, fear, panic disorder, anxiety or depression
    • gastrointestinal, such as gastroesophageal reflux disease, esophagitis or pancreatitis
    • infection, such as pericarditis, shingles
    • muscle strain or overuse, such as costochondritis or cervical radiculopathy
    • pulmonary disorder, such as pulmonary embolism, tension pneumothorax, pleurisy or pneumonia
    • stimulant drug use, such as cocaine or methamphetamine

    Initial Assessment

    • airway patency
    • breath sounds
    • cardiovascular status
    • emotional and behavioral status
    • general appearance
    • hemodynamic status
    • neurologic status
    • oxygen saturation
    • pain level
    • pain onset and characteristics
    • peripheral vascular status, edema
    • respiratory effort and pattern

    History

    • allergies
    • comorbidties
    • immunization status
    • last menstrual period (femaies of childbearing age)
    • medications
    • appetite and diet history
    • behavioral health history
    • cardiac history, including myocardial ischemia, procedures, surgeries
    • functional status, including effect on activity
    • pain characteristics, onset, duration, intensity, radiation, pattern, alleviating and aggravating factors
    • precipitating events, such as activity (exercise, sex), weather exposure, diet, stressors or life changes
    • recent exposure to toxin or illicit drug use, such as a stimulant
    • recent illness, infection, trauma, muscle strain or overuse
    • recently postpartum
    • smoking history and status

    Laboratory Studies

    • calcium
    • cardiac troponin
    • CBC (complete blood count) with differential
    • magnesium
    • serum creatinine
    • serum electrolytes

    Diagnostics

    • 12-lead ECG (electrocardiogram)

    Potential Additional Testing

    • BNP (B-type natriuretic peptide)
    • chest x-ray
    • coagulation studies abnormal
    • coronary angiography
    • CRP (C-reactive protein)
    • CT (computed tomography) scan abnormal
    • D-dimer
    • Doppler exam
    • echocardiogram
    • pregnancy testing (females of childbearing age)
    • serum glucose
    • urine or serum drug screen

    Problem Intervention

    Provide Respiratory Support

    • Assess and monitor airway, breathing and circulation; maintain close surveillance for deterioration.
    • Maintain open and patent airway.
    • Position to minimize the risk of aspiration, ventilation-perfusion mismatch and breathlessness.
    • Minimize oxygen consumption and demand.
    • Provide oxygen therapy judiciously; titrate to prevent hyperoxemia.
    • Implement noninvasive or invasive positive pressure ventilation to support oxygenation and ventilation, as well as relieve respiratory distress.

    Problem Intervention

    Provide Hemodynamic Support

    • Monitor cardiovascular status, including blood pressure, peripheral pulses, ECG (electrocardiogram) and peripheral oxygen saturation.
    • If patient remains symptomatic following a nondiagnostic ECG (electrocardiogram), frequent ECG (electrocardiogram) evaluations should be continued.
    • Observe for and address cardiac dysrhythmia; monitor for and replace electrolytes; anticipate use of vagal maneuvers, administration of an antiarrhythmic agent, cardioversion or pacemaker insertion.
    • Support perfusion with body positioning, such as head of bed elevated or flat with legs elevated.
    • Evaluate fluid status; provide fluid therapy to improve blood flow, perfusion and tissue oxygenation.
    • Anticipate urgent intervention in the presence of hemodynamic instability that may include inotropic or vasopressor agent administration, cardiopulmonary resuscitation or defibrillation.

    Problem Intervention

    Monitor and Manage Pharmacologic Therapy

    • Prepare for medication administration, which may include an antiplatelet agent, such as aspirin, nitrate, beta-blocker, calcium channel blocker, ACE (angiotensin-converting enzyme) inhibitor, angiotensin receptor blocker or anticoagulant.
    • In patients with ST-elevation myocardial infarction and symptom onset within the past 12 hours, anticipate pharmacologic reperfusion with a fibrinolytic agent, preferably within 30 minutes of arrival.
    • In patients with cocaine-induced heart ischemia, anticipate administration of an antiplatelet agent, such as aspirin, nitrites and a benzodiazepine agent.
    • Monitor physiologic response.
    • Consider administration of influenza and pneumococcal pneumonia vaccinations.

    Problem Intervention

    Promote Comfort and Manage Pain

    • Use a consistent pain assessment tool; evaluate pain and treatment response at regular intervals.
    • Involve patient and family/caregiver in the management plan.
    • Provide nonpharmacologic strategies, such as positioning, heat or cold application, rest, distraction or relaxation techniques.
    • Consider pharmacologic measures, such as acetaminophen, nonsteroidal anti-inflammatory, morphine, antacid, histamine2 receptor blocker or proton-pump inhibitor.
    • Evaluate risk for opioid use and dependence.

    Problem Intervention

    Provide Psychosocial Support

    • Proactively provide information; encourage questions and address concerns.
    • Provide calm, reassuring presence.
    • Recognize, identify and allow expression of emotions.
    • Promote family/caregiver presence at bedside.
    • Offer choices to enhance a sense of control.
    • Honor spiritual and cultural preferences.
    • Recognize and utilize personal coping strategies.

    Problem Intervention

    Facilitate Procedures

    • Initiate and maintain NPO (nothing by mouth) status.
    • Prepare for or assist with procedures, such as cardiac catheterization, fibrinolytic therapy, pericardiocentesis, chest tube placement or angiography.
    • Anticipate and prepare for surgical intervention, such as invasive angiography or coronary revascularization.

    Problem Intervention

    Initiate Consult or Referral

    • Facilitate contact, such as a cardiologist, pulmonologist or cardiovascular surgeon.
    • Coordinate follow-up appointment.

    Education

    General Emergency Education

    Teaching Focus

    • symptom/problem overview

    • risk factors/triggers

    • self-management

    • assistive device

    • diagnostic test

    • diet modification

    • medical device/equipment use

    • medication administration

    • opioid medication management

    • orthopaedic device

    • safe medication disposal

    • smoking cessation

    • wound care

    Population-Specific Considerations

    Forensics and Legal

    • Utilize local, state/province, federal requirements and hospital policy and protocols to manage patient care involving forensics, protective services, workman’s compensation and mandatory reportable events and illness.

    Human Trafficking

    • Human trafficking victims most frequently seek healthcare services from Emergency Departments. Healthcare professionals, alert to signs of trafficking, can guide supportive care for victims.
    • Trafficked individuals may be male or female and engaged in sex work or other forced labor. High-risk signs requiring more direct questioning about exploitation include, among others, current employment in a high-risk industry, prior sexually transmitted infections, recent immigration, undocumented immigrant status and other vulnerable and minority populations.

    Geriatric

    • Rates of atypical presentation of acute coronary syndrome are higher in older adults, which leads to worse prognosis.
    • Dyspnea is the most common symptom of myocardial ischemia in patients over 85 years of age.
    • Older adults have an increased sensitivity to medications and toxins, decreased renal function and cardiovascular resilience, as well as decreased ability to react to volume and electrolyte changes.
    • A urinalysis should be performed if also presenting with an altered level of consciousness.
    • It’s important to determine and honor previous advanced care plan directions.

    Pregnancy

    • Beyond 20 weeks gestation, supine position should be avoided. Maternal position should be lateral or lateral tilt to prevent compression of the inferior vena cava and aorta by the pregnant uterus.
    • Maternal stabilization is a priority. Assessment of fetal heart tones and contraction activity should be done quickly. Continuous fetal monitoring may be indicated.
    • Some dyspnea occurs normally due to advancing pregnancy, but should not be associated with chest pain.
    • During pregnancy, blood volume and cardiac output are significantly increased. Patient is in a hyperdynamic, hypervolemic state.
    • Hypoxemia may develop more quickly due to uterine displacement of the diaphragm and decreased functional reserve.
    • Many cardiovascular medications are contraindicated in the pregnant patient requiring careful evaluation before prescribing.

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    Disclaimer

    Clinical Practice Guidelines represent a consistent/standardized approach to the care of patients with specific diagnoses. Care should always be individualized by adding patient specific information to the Plan of Care.

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