Standing orders for chest pain

Specialties Cardiac

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d'cm

284 Posts

A little off subject here but readers might find it interesting.. As a UR / Appeals RN I've looked at hundreds of chest pain admissions and have some opinions and observations. 1. Chest pain rarely is proven as an acute ischemic event ( when I say rarely, I'm would guestimate

Ruling out or in ACS should be first priority. This is done with EKG/ tropinins and thorough patient hx. Consider getting a TIMI score before administering anything.

Specializes in Med/Surg, Tele, PCU.
A little off subject here but readers might find it interesting.. As a UR / Appeals RN I've looked at hundreds of chest pain admissions and have some opinions and observations. 1. Chest pain rarely is proven as an acute ischemic event ( when I say rarely, I'm would guestimate

Ruling out or in ACS should be first priority. This is done with EKG/ tropinins and thorough patient hx. Consider getting a TIMI score before administering anything.

That is indeed a very interesting set of facts. As a nurse still ever learning about cardiac issues, i have seen ST depressions to be considered baseline for patients with CAD or CHF, other cardiac issues. But on the other side of the coinf, it's my understanding that the heart can't go for more than 6 minutes without proper perfusion before myocardial injury sets in. So How could ischemia be a baseline? Can someone clear this up for me?

With regard to chest pain, I've been doing research on the several types of descriptions used by patients to describe their chest pain. I have read many instances where patient has come in through ER c/o chest pain and has been sent home when in fact the pt. was having an MI. I don't know, I've come to the point where i would rather err on the side of precaution. Pt. complains of MI, whether symptomatic or not, I call the doctor because in the long run, it's the nurse that gets dinged if the pt. had an MI and didn't call the doctor.:yeah:

nursej22, MSN, RN

3,810 Posts

Specializes in Public Health, TB.

ST and T wave abnormalities can appear chronically, that is why enzymes and other testing is usually done (echo, stress test), and having an old 12 EKG can be valuable for comparison.

T wave inversion can be seen post MI and may continue, but usually resolves after several weeks. It is also seen in RBBB.

ST depression and T wave inversion may appear in left ventricular hypertrophy or volume overload of the left ventricle. You will usually also see increased voltage in the precordial leads.

Most 12 lead classes that I have been to say that ischemia cannot be seen on a 12 lead in a patient with BBB, a pacemaker or LVH.

Digitalis toxicity can also result in ST-T wave abnormalities.

Specializes in Med/Surg, Tele, PCU.
ST and T wave abnormalities can appear chronically, that is why enzymes and other testing is usually done (echo, stress test), and having an old 12 EKG can be valuable for comparison.

T wave inversion can be seen post MI and may continue, but usually resolves after several weeks. It is also seen in RBBB.

ST depression and T wave inversion may appear in left ventricular hypertrophy or volume overload of the left ventricle. You will usually also see increased voltage in the precordial leads.

Most 12 lead classes that I have been to say that ischemia cannot be seen on a 12 lead in a patient with BBB, a pacemaker or LVH.

Digitalis toxicity can also result in ST-T wave abnormalities.

Thank you nursej22. Great Information. I don't exactly know where my career path is going to take me, but I really want to get involved with Cardiac. LOVE IT.....!

Think I'm going to start by taking a 12-lead class.:yeah:

CCL RN, RN

557 Posts

Specializes in Cath Lab/ ICU.
. Pt. complains of MI, whether symptomatic or not, I call the doctor because in the long run, it's the nurse that gets dinged if the pt. had an MI and didn't call the doctor.:yeah:

Pts rarely, if ever, c/o of an "mi"

MIs that are missed are those that complain of nausea, indigestion, DB/SOB, shoulder pain, etc, etc. In fact, lots of NSTEMIs present with very vague symptoms. Many do not get troponins drawn, or only have one set and they are negative. Many have angina, but no real damage, no troponin bump, and s/s so vague that they don't even consider cardiac.

Recently, we had a NSTEMI, with a very mild troponin bump. Still

Anyhow, we almost didn't cath him because he didn't look like a "real case"

He had triple vessel disease, with his left main, (left main!!!) hanging on by a thread.

Anyway, my rambling point was, MIs can be insidious. They may lurk and look like something completely different. You'd be surprised how easily they can be missed...

Specializes in Med/Surg, Tele, PCU.
Pts rarely, if ever, c/o of an "mi"

MIs that are missed are those that complain of nausea, indigestion, DB/SOB, shoulder pain, etc, etc. In fact, lots of NSTEMIs present with very vague symptoms. Many do not get troponins drawn, or only have one set and they are negative. Many have angina, but no real damage, no troponin bump, and s/s so vague that they don't even consider cardiac.

Recently, we had a NSTEMI, with a very mild troponin bump. Still

Anyhow, we almost didn't cath him because he didn't look like a "real case"

He had triple vessel disease, with his left main, (left main!!!) hanging on by a thread.

Anyway, my rambling point was, MIs can be insidious. They may lurk and look like something completely different. You'd be surprised how easily they can be missed...

Thanks so much for your input. Definitely was not rambling. You are right on target. I meant to say c/o chest pain not MI. But either way, your answer is right on target. :yeah:

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