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