Guidelines for ED Observation of Chest Pain
May 1, 2002 2 minutes read
Guidelines for ED Observation of Chest Pain
TRANSFER CRITERIA
- Clinical suspicion that risk of myocardial infarction is less than 6% (see Goldman algorithm).1
- Chest discomfort is potentially cardiac ischemia (Based on risk factors / discomfort)
- Normal electrocardiogram, or concurrence with cardiologist/private medical doctor
- Acceptable vital signs
- No history of known coronary artery disease, or concurrence with cardiologist/private medical doctor
EXCLUSION CRITERIA
- Clinical suspicion that risk of myocardial infarction is more than 6% (see Goldman algorithm)
- Electrocardiogram which shows evidence of myocardial infarction or clearly acute injury/ischemia pattern
- Unstable vital signs
- Clear unstable angina by history (i.e. known coronary artery disease, symptoms like prior angina/ myocardial infarction)
- Chest pain is clearly not cardiac ischemia
- Private attending chooses inpatient admission
INTERVENTIONS
Initial emergency department intervention:
- IV (heplock?), oxygen, Telemetry Monitor System hook up, initial electrocardiogram, chest X-ray, NO caffeine.
- If not contraindicated, give aspirin 325 mg by mouth, (consider Maalox 30 cc by mouth).
- Appropriate nitrates (physician discretion) — Nitroglycerine SL prn, Nitro Paste, or Nitrobid.
- Send initial biomarker(s) — Creatinine phosphokinase (CPK-MB), possibly Myoglobin or Troponini.
- Emergency attending physician speaks with primary medical doctor or chest pain center cardiologist, choose stress test option.
- If appropriate, Resting Cardiolyte Injection. Scan if feasible (i.e. time of day).
Emergency department observation unit interventions:
- Call lab to add myoglobin to initial blood drawn in Emergency Center
- Continue IV (heplock), oxygen, Telemetry Monitor System (ST segment) Monitor, Nitrates, No caffeine.
- Send patient to obtain initial resting scan if ordered.
- Perform electrocardiogram based on clinical suspicion or electrocardiogram "ST segment" monitor alert. Show Emergency Attending Physician/Physician Assistant stat.
- Protocol = Time 0- and 4-hour electrocardiogram, MB isoform creatine kinase enzyme (CK-MB), and Myoglobin
If all tests are negative => appropriate stress test
If abnormal CK-MB or Electrocardiogram => admit IF:
- (a) No stress test planned,
- (b) ONLY myoglobin is elevated,
- (c) 0 to 4hr CK-MB /Myoglobin doubled, or
- (d) four-hour tests are missed:
Time eight-hour Electrocardiogram, CK-MB, Troponin T IF
- If all tests are negative => appropriate stress test
- If abnormal CK-MB, Troponin T, or Electrocardiogram => admit
DISPOSITION
Home —
- Acceptable vital signs
- Normal biomarkers
- Unremarkable stress test
- No significant electrocardiogram changes
Hospital —
- Unstable vital signs
- Positive biomarker
- Electrocardiogram changes
- Significant stress test abnormality
- Emergency attending physician/private medical doctor clinical discretion
1/17/01
REFERENCE
1. Goldman L. Prediction of the need for intensive care in patients who come to the emergency department with acute chest pain. N Engl J Med 1996; 334:1,498-1,504.
Source: William Beaumont Hospital, Royal Oak, MI.
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