Chest pain protocol in the ER

  1. Does your Emergency Room have a Chest Pain protocol? If so what are the orders?
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  2. 21 Comments

  3. by   scrmblr
    ekg in 5min.
    start a line draw the blood-order the cardiac panel
    nitro sl x3-depends on b/p
    asa @ 325mg
    ox at 2lt
    md to see ekg within 5minutes
    morphine is a sticky point-we have a "pain protocol" that includes being able to pull morphine for chest pain without a doc's order. I hesitate to use it-only if the doc is impossibly busy.
  4. by   Altra
    Our protocol is the same as scrmblr's above.

    If the EKG & monitor look like the pt. will be going to the cath lab, I go ahead & start a 2nd line & get the nitro tubing & pumps for NTG, heparin, cardizem ... whatever we end up doing.

    Our protocol to get a pt. to the cath lab is 30 min. from the time the decision is made ... but ... if the cath lab is ready sooner than that, the patient goes up. We do not delay to hang heparin, etc. As long as the rhythm is stable enough that we're comfortable with the trip in the elevator, the patient goes.
  5. by   StillBelieveRN
    Quote from scrmblr
    ekg in 5min.
    start a line draw the blood-order the cardiac panel
    nitro sl x3-depends on b/p
    asa @ 325mg
    ox at 2lt
    md to see ekg within 5minutes
    morphine is a sticky point-we have a "pain protocol" that includes being able to pull morphine for chest pain without a doc's order. I hesitate to use it-only if the doc is impossibly busy.
    Do you place the patient on a monitor?!?!?
  6. by   RunnerRN
    Ours is similar to above, but a little different. Ours includes:
    Monitor, O2, IVSL w blood draw (if we're really busy I'll send CBC, CMP, coags, and hold the cardiac panel), EKG in 5 min, ASA 324mg chewable if no contraindications or pt hasn't taken already.

    Our docs are really particular about the cardiac panel. Their reasoning is the liability...how one troponin doesn't tell you anything if onset of pain is less than 6-8 hours in duration, so they'd be forced to admit and draw serial trops (although, in general, if you come in w c/o CP, 90% of the time you'll be admitted).
    Our protocol is also only for pts over 30. We don't include NTG.
  7. by   Altra
    Quote from RunnerRN
    Our docs are really particular about the cardiac panel. Their reasoning is the liability...how one troponin doesn't tell you anything if onset of pain is less than 6-8 hours in duration, so they'd be forced to admit and draw serial trops (although, in general, if you come in w c/o CP, 90% of the time you'll be admitted).
    Our protocol is also only for pts over 30. We don't include NTG.
    This is a good point about cardiac enzymes. But we send them because, as you pointed out, 90% of the time the pt. will be admitted unless their CP can really be demonstrated to be related to a respiratory issue, muscular pain, or anxiety. So theoretically if all is well, drawing the first set now will shorten their stay by 4 hours.

    On a young person, unless their vitals or EKG look crappy I will usually do the EKG only, until the doc has seen them & decides which way we're going to go with this.
  8. by   nuangel1
    i agree with the above .ekg within 10 min monitor vs o2 iv labs drawn and sent including troponin ..dr see's ekg immed.if changes 2 nd iv line .we have cath lab protocol to lab within 30 min and we don't wait to hand anything .when lab is ready we move the pt.
  9. by   meandragonbrett
    We get an ekg, o2, monitor, ASA, Beta Blocker, Morphine, Nitro and then go from there.
  10. by   tiredfeetED
    Quote from meandragonbrett
    We get an ekg, o2, monitor, ASA, Beta Blocker, Morphine, Nitro and then go from there.
    pretty much the same except the Betablocker...most docs in our ED would freak if the RN started adminstering a bb on a chest pain due to protocol. We also get a PCXR and IV with cardiac markers.
  11. by   TazziRN
    We don't have a written protocol but the docs expect us to:

    monitor and O2
    get an EKG and CXR
    start a line and draw cardiac labs
    have nitro ready to give and be prepared for a morphine order

    If it truly is an evolving or recent MI, start at least one more line and call the tertiary care facility to get a transfer started for a cardiac cath.
  12. by   meandragonbrett
    Our protocol includes giving PO metoprolol as long as not contraindicated.
  13. by   hispanicpanic
    EKG 5min, with MD read
    Nitro SL x3, hold for BP<100
    AC PIV (at least 20g)
    Cardiac Labs
    2L O2
    Cardiac Monitor with SPO2
  14. by   neneRN
    All CP pts go through a chest pain screening area, staffed by an RN and a tech, where a cardiac risk factor/PE screening flow sheet, EKG within 10 minutes, monitor, O2, IV and labs drawn, bedside troponin and Chem 8, ASA x 4 are completed, then pt is sent to different ER room to see MD. Nurses love this, because all the chest pain pts are already worked up when you get them. And its a nice break for the nurse working the screening area, never have a pt longer than 15 minutes!

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