MANAGEMENT OF CHEST PAIN SUGGESTIVE OF ISCHEMIA

+-----------------------------------------------------------------------+
| GOALS                                                                 |
|                                                                       |
| Immediate assessment of patients with chest pain.                     |
|                                                                       |
| Timely initiation of treatment.                                       |
|                                                                       |
| Rapid determination of need for transfer to another facility.         |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| MAA immediately notifies triage nurse of patient checking in with     |
| chest pain                                                            |
|                                                                       |
| or                                                                    |
|                                                                       |
| Patient informs nurse or healthcare provider of chest pain.           |
+-----------------------------------------------------------------------+

+-------------------------------+----+---------------------------------+
| # Nursing Assessm             |    | Orders for Immediate Treatment  |
| ent -- The following must be  |    |                                 |
| completed within 10 minutes o |    | Determine cardiac rhythm on     |
| f notification of chest pain: |    | monitor.                        |
|                               |    |                                 |
| Assess pain level: quality,   |    | Labs --Troponin with results    |
| duration, location,           |    | within one hour of draw, CBC,   |
| radiation.                    |    | SMA7, CK-MB, PT, PTT, U/A       |
|                               |    |                                 |
| Check vital signs, including  |    | Aspirin 325 mg chewable         |
| SaO~2\ .~                     |    |                                 |
|                               |    | if no ASA taken in past 3       |
| Start oxygen at 4 liters/min  |    | hours.                          |
| nasal cannula.                |    |                                 |
|                               |    | Nitroglycerine 0.4 mg sl if     |
| Obtain 12 lead EKG.           |    | BP\>100 systolic.               |
|                               |    |                                 |
| Notify Provider of patient    |    | Repeat x 2 five minutes apart   |
| with chest pain.              |    |                                 |
|                               |    | if chest pain not relieved.     |
| Provider interprets EKG       |    |                                 |
|                               |    | Insert saline lock.             |
| **\*\*For CBOC patients call  |    |                                 |
| 911.** EMT's will administer  |    | Monitor vital signs q 15        |
| meds/tx per their protocol.   |    | minutes.                        |
|                               |    |                                 |
|                               |    | Morphine IV as per provider if  |
|                               |    | chest pain not relieved by      |
|                               |    | nitroclycerine.                 |
|                               |    |                                 |
|                               |    | Beta blockers as per provider   |
|                               |    | if deemed beneficial.           |
+-------------------------------+----+---------------------------------+

  -----------------------------------------------------------------------
  EKG Findings

  -----------------------------------------------------------------------

+-------------------------------+----+---------------------------------+
| ## EK                         |    | ## EKG -- Non-ST elevation      |
| G -- ST elevation or new LBBB |    |                                 |
+-------------------------------+----+---------------------------------+

+------------------------------+-----+---------------------------------+
| Provider to call ER at       |     | Determine TIMI Score            |
| Vassar 454-8500              |     |                                 |
|                              |     | Obtain Cardiology consultation, |
| / HVH 914-737-9000,          |     |                                 |
|                              |     | via call to Manhattan VA during |
| obtain accepting physician.  |     | when hours.                     |
|                              |     |                                 |
| Initiate immediate ACLS      |     | Determine disposition based on  |
| transport.                   |     | provider assessment, and TIMI   |
|                              |     | score recommendations           |
| Start lovenox 1mg/kg sq if   |     |                                 |
| no contraindication          |     |                                 |
+------------------------------+-----+---------------------------------+

+-----------------------------+-----+----------------------------------+
| TIMI score is a simple      |     | TIMI Score                       |
| prognostic tool used to     |     |                                  |
| categorize a patient's risk |     | \_\_\_ Age over 65               |
| of death and ischemic       |     |                                  |
| events and provides a basis |     | \_\_\_ 3 or more risk factors    |
| for therapeutic decision    |     | for coronary disease\*           |
| making.                     |     |                                  |
|                             |     | \_\_\_ Established CAD           |
| [Score]{.underline} [Risk   |     |                                  |
| Factor]{.underline}         |     | \_\_\_ 2 or more anginal events  |
|                             |     | in past 24 hours                 |
| 0-1 4.7%                    |     |                                  |
|                             |     | \_\_\_ Use of ASA in past 7 days |
| 2 8.3%                      |     |                                  |
|                             |     | \_\_\_ Elevated enzymes          |
| 3 13.2%                     |     |                                  |
|                             |     | \_\_\_ ST depression             |
| 4 19.9%                     |     | [\>]{.underline} 0.5mm           |
|                             |     |                                  |
| 5 26.2%                     |     | Number of checks = TIMI Score    |
|                             |     | \_\_\_\_\_\_                     |
| 6-7 40.9%                   |     |                                  |
|                             |     | \*Risk Factors = hypertension,   |
|                             |     | cigarette smoking, obesity,      |
|                             |     | physical inactivity,             |
|                             |     | dislipidemia, DM,                |
|                             |     | micro-albuminuria, GFR \<60/min, |
|                             |     | family h/o premature CVD         |
+-----------------------------+-----+----------------------------------+