Chest Pain – Physiomi

Intravenous Fluid Orders

Intravenous Cannula – Insert
IV Peripheral Saline Flush/Lock: Saline Lock
- IV Maintenance:
  - 0.9% NaCl infusion at ______ mL/hour, reassess after hours
  - lactated ringers infusion at ______ mL/hour, reassess after hours
IV Bolus:
- 0.9% NaCl ______ mL over ______ hour(s)
- lactated ringers _______ mL over _______ hour(s)

Laboratory Investigations

Hematology

Complete Blood Count (CBC)
PT INR

Chemistry

Troponin
Repeat Troponin_________time(s) (specify collection time below)
- ___________:_____________
- ___________:_____________
Electrolytes (Na, K, Cl, CO2)
Glucose
Creatinine
Urea
Serum bHCG

Urine Tests

Urine Dipstick Testing – POCT
Urinalysis
Pregnancy Test, Urine (POCT if available)

Other Labs (based on presentation needs of the patient)

Diagnostic Imaging

Chest x-ray usually indicated unless recently performed to rule out pneumonia, CHF, pneumothorax, etc.

Chest X-Ray 2 projections (GR Chest PA and Lateral)
Chest X-Ray 1 projection: Portable (GR Chest Portable)
CT Chest Enhanced

Other Investigations

Electrocardiogram
- 15 Lead (if signs of inferior ischemia or anterior ST depression)
- 12 Lead every minutes, times (if ongoing symptoms suggestive of cardiac ischemia)
- 12 Lead PRN for recurrent episodes of chest pain

Medications

Antiplatelet Agents

Should be administered to all patients at high risk of Acute Coronary Syndrome (ACS) as soon as practical after ED arrival if not taken by patient or administered by EMS prior to arrival. It is reasonable to delay acetylsalicylic acid (ASA) administration in low-risk patients or until an ACS diagnosis has been confirmed.

acetylsalicylic acid CHEW tab (ASA) 160 mg PO STAT x 1 dose UNLESS already administered during current presentation followed by ASA enteric coated 81 mg PO daily

If true allergy to ASA or confirmed ACS

Choose ONE only

ticagrelor 180 mg PO once (preferred agent for patients undergoing Percutaneous Coronary Intervention [PCI])

clopidogrel (specify dosage):
- 300 mg PO once
- 600 mg PO once

Nitrates

nitroglycerin SL spray (each spray delivers 0.4 mg nitroglycerin) 1 spray sublingually every 5 minutes PRN up to 5 doses; Notify authorized prescriber if persistent symptoms after 3 doses; HOLD if SBP less than 100 mmHg

If sublingual nitroglycerin ineffective and high probability of cardiac chest pain consider nitroglycerin infusion. Avoid nitroglycerin infusion in patients with systolic blood pressure less than 100, in MI with inferior/right-sided involvement or recent use of phosphodiesterase inhibitors (sildenafil or tadalafil within 24 hours).

nitroglycerin infusion (non-weight based)
- Start at 5 microgram/min IV continuous; increase by 5 to10 microgram/min q3 to 5 minutes as needed up to 20 micrograms/min; then by 10 to 20 microgram/min q3 to 5 minutes, as needed, to a maximum of 200 microgram/min

nitroglycerin infusion (weight based)
- Start at 0.1 to 0.2 microgram/kg/min IV continuous; increase by 0.1 microgram/kg/min q3 to 5 minutes as needed up to 0.3 microgram/kg/min; then by 0.2 to 0.4 microgram/kg/min q3 to 5 minutes, as needed, to a maximum of 200 microgram/min

Opiate Analgesia

Consider opiate analgesia if persistent symptoms of ischemic chest pain despite maximal anti-ischemic therapy. For “susceptible patients” defined as elderly, frail, low body mass, systemically unwell, or on medications known to cause sedation or lower blood pressure we recommend decreasing narcotic dosing by 50%.

Notify physician or nurse practitioner for reassessment if pain not controlled after administration of maximum dosage.
HYDROmorphone 1 mg IV once
HYDROmorphone 0.5 to 1 mg every 10 minutes PRN for pain (maximum 3 mg total)
HYDROmorphone _ mg IV every minutes PRN for pain

Suggest 0.5 mg for moderate pain and 1 mg for severe pain

fentaNYL 50 micrograms IV once
fentaNYL 25 to 50 micrograms IV every 5 minutes PRN for pain (maximum 200 micrograms total) o fentaNYL mcg IV every minutes PRN for pain

Suggest 25 mcg for moderate pain and 50 mcg for severe pain

morphine 2.5 to 5 mg IV q15min PRN (maximum of 20 mg before speaking to physician)

Antiemetics

Avoid dimenhyDRINATE in patients 65 years of age or older due to increased risk of side effects including delirium. Suggest 25 mg for mild/moderate nausea, 50 mg for moderate/severe nausea.

dimenhyDRINATE 50 mg PO once
dimenhyDRINATE 25 to 50 mg PO every 4 hours PRN for nausea/vomiting
dimenhyDRINATE mg PO every hours PRN for nausea/vomiting
dimenhyDRINATE 50 mg IV once
dimenhyDRINATE 25 to 50 mg IV every 4 hours PRN for nausea/vomiting
dimenhyDRINATE mg IV every hours PRN for nausea/vomiting

Oral administration or slow infusion via IVPB are preferred for metoclopramide to reduce the risk of akathisia. Suggest 5 mg for mild/moderate nausea or if CrCl less than 40 mL/min; 10 mg for moderate/severe nausea, and CrCl over 40 mL/min

metoclopramide 10 mg PO once
metoclopramide 5 to 10 mg PO every 6 hours PRN for nausea/vomiting
metoclopramide mg PO every hours PRN for nausea/vomiting
metoclopramide 10 mg IVPB once
metoclopramide 5 to 10 mg IVPB every 6 hours PRN for nausea/vomiting
metoclopramide mg IVPB every hours PRN for nausea/vomiting

4 mg starting dose recommended for IV ondansetron. Avoid ondansetron in patients with prolonged QTc interval.

ondansetron 4 mg IV once
ondansetron 4 mg IV every 8 hours PRN for nausea/vomiting
ondansetron mg IV every hours PRN for nausea/vomiting
ondansetron tab 8 mg PO every 8 hours PRN for nausea/vomiting
ondansetron tab mg PO every hours PRN for nausea/vomiting

Due to high cost, recommend reserving ondansetron DISINTEGRATING tab for actively vomiting patients without an IV

ondansetron DISINTEGRATING tab 8 mg PO every 8 hours PRN for nausea/vomiting
ondansetron DISINTEGRATING tab mg PO every ___ hours PRN for nausea/vomiting

Patient Care

Monitoring

Vital Signs (respiratory rate, pulse, blood pressure, temperature, oxygen saturation)
- as per provincial guideline http://insite.albertahealthservices.ca/assets/policy/clp-ed-assess-reassess-pts-guideline-hcs-181-01.pdf
- o every hour(s) o manual o automatic
- o every minutes o manual o automatic

Patients with unstable hemodynamics or ongoing symptoms consistent with cardiac chest pain should have continuous cardiac and pulse oximetry monitoring. Patients with atypical chest pain may not need monitoring. Patients who are symptom-free do not require continuous cardiorespiratory monitoring.

Bedside Cardiac Monitoring
Oxygen Saturation Monitoring – Continuous

Respiratory Care

If oxygen saturation is already adequate (GREATER than 90%), no supplemental oxygen is required.

O2 Therapy – Titrate to maintain SpO2 greater than or equal to 90%
Notify physician if O2 flow required to be increased by greater than 2 L to maintain the same level of oxygenation, if there is a progressive increase in work of breathing, hypotension, or decreased or altered level of consciousness (LOC).

Diet / Nutrition

NPO
NPO: May Take Meds
Regular Diet
Other Diet:

Other Orders

Consult Cardiology
Consider accessing the HEART Score to assist with risk stratification during the consultation process: http://www.mdcalc.com/heart-score-for-major-cardiac-events/

Reference: https://www.albertahealthservices.ca/frm-20746-bond.pdf