Chest Pain

Question 1

Pt presents to the clinic for chest pain… what 4 things should be quickly assessed to ID where the pt should go next?

Answer 1

Brief Hx of CP
Appearance
Vitals
Signs of hemodynamic compromise (see anemia for signs of hemodynamic compromise)

Question 2

If pt is assessed as unstable with CP, what should you do regardless of etiology?

Answer 2

Transport ASAP to ED via ambulance with defibrillator
Stabilization as much as possible (typically in ambulance): IV access, cardiac monitor, oxygen (breathlessness, hypoxemia, or Sx of heart failure/shock)

Question 3

If you suspect ACS in a pt with acute CP, what should you give?

Answer 3

1. 325 mg aspirin (chewed, swallowed)
2. 0.4 mg sublingual Nitroglycerin x 3 over 15 minutes (unless pt has hypotension w/o IV access, recently taken Phosphodiesterase inhibitor - Sildenafil)
3. 12-lead ECG and blood sample for cardiac enzyme measurement if possible
4. ER will do further assessment

*maybe oxygen if appropriate

Question 4

If the pt is assessed as stable with CP, what life threatening etiologies should be considered?

Answer 4

ACS
PE
Aortic dissection
Pneumothorax
Esophageal rupture

Question 5

Considering CP, when does a pt HAVE to be referred to the hospital?

Answer 5

Unstable pt (ambulance transport)
Emergent conditions cannot be ruled out (ambulance transport)
Altered LOC (ASAP referral to specialist or ED)
Increasing instability of previous stable condition (ASAP referral to specialist or ED)

Question 6

Considering CP, when does a pt need pharmaceutical intervention for chronic stable angina?

Answer 6

Rx sublingual nitro

Question 7

Considering CP, when does a pt need pharmaceutical intervention for increasing instability of previously stable angina?

Answer 7

Rx anti-anginas and/or referral

Question 8

What are required monitoring at every visit with a pt with chest pain?

Answer 8

Hemodynamic stability, O2 sat, fluid sequestration
Change in pain severity, freq, duration
DOE, SOB at rest, PND, orthopnea
Peripheral edema
Changes in ADLs limitation
Change in freq/efficacy of previously palliative agents

Question 9

What are required follow up and management with a pt with chest pain?

Answer 9

Constant until stability SURE
Hrly-daily until life-threatening conditions ruled out
Daily-weekly until underlying cause of pain found or after severe exacerbation, hospital stay, or ED visit
Weekly-Monthly for chronic concerns after change in stability, med change, or management change
Monthly-semi-annual for well managed, controlled, chronic complaint