Assessing Acute Coronary Syndrome

candyndel · Feb 1, 2005

I am not sure what you are asking for.

People present very differently, women especially, and if we pick and choose who we think is a true ACS, we are headed for disaster. Chest pain protocols should be developed & followed for everyone who meets the defined criteria.

Case in point...

Last week we had a 42 yo female with neck and throat pain. She got toradol and C spine films. While in xray (3 hours later), she became syncopal and diaphoretic. Immediate ECG showed HUGE AWMI.

Two weeks ago, we had a 42 yo guy who had chest pain that became worse with inspiration. The medics didnt think it was cardiac (bc it was reproducible) and TSO'ed him. He came to us and went into pulseless Vtach during triage. We shocked him 42 times (i kid you not), started amiodarone, and took him to the cath lab.

He got 3 stents and was d/c 7 days later. Upon dc, he came down to thank the ED and had everyone in tears.

Okay this is a bit of exploratory "research" if you will. I recently was asked to write some core competencies for Coronary Care and in the process did some literature reviews. Some of which have brought to light what is called "practice wisdom" - those hints and tricks that may or may not be in the textbook but are handed down from nurse to nurse and which are true!! I don't want to post what I found straight up because I don't want to "contaminate" any answers but I will post the information along with references later;)
So the topic is Assessment of Acute Coronary Syndrome (ACS) and in particular how to differentiate between the patient who has chest pain and Non-cardiac Chest pain as well as differentiating between Angina and MI pain.
Hints:- don't confine it to pain think about patient behaviours, attitudes, expressions, topics of conversation, skin colour, etc.

UM Review RN, ASN, RN · Feb 1, 2005

Coworker had one LOL who was very demanding all night, kept wanting to be repositioned. We moved her around the bed in microscopic degrees about q 15 minutes. By about 0330, we were getting a tad tired of the Princess & the Pea.

Finally, she began c/o GERD (and she had a hx of GERD) and nausea. She vomited a little. We got an EKG per protocol and tried some Mylanta because of her epigastric discomfort.

The EKG showed she was having an AMI. :uhoh21: I recall this so well because her s/s were so atypical.

We get a lot of "silent MIs" where I work partly because we deal with a population that is older and with lots of diabetics.

Most of the time, our younger CP folks are having some kind of pneumonia, a PE, or a problem with their gallbladder or an ulcer. I can't really tell the difference without labs, and I doubt anyone else can either. Which is why we joke about some patients coming to our ER. We kid that they could come in c/o being constipated and they'd start a CP r/o MI protocol because we're so hot on f/u of anything that remotely could be an MI.

gwenith, BSN, RN · Feb 2, 2005

The article that started this suggested that many nurses have added criteria that assisted the nurse in assessing cardiac pain. These criteria "raised the level of suspicion" if you will and I was hoping someone would be able to come up with these independant of me actually stating them.

The two indicators were "diminished energy" and inward focus. I have to admit to seeing a LOT of patients with both of those criteria and they are alarm bell criteria for me. Turn it around - if you have a patient who is complaining of chest pain and is at the same time running around the unit wanting to know what is on the telly and trying to see how fast they can get to the drink machine and back - do you think that they are having an MI??

JessicRN · Feb 3, 2005

We had a 40 year old come in c/o of chest pain for 3 days after having taken Viagra. His EKG was normal but his troponin level was elevated. He spent 3 hours sitting in our ER during the night saying he had no further chest pain when I came on I noticed the cardiac monitor showed ST elevation in lead 11. I was told everything was fine and the pt looked and felt great. I did another EKG 3 hours after the first one and found he was having an inferior MI. He had a 100% occlusion of his rt coronary artery. He was unblocked and is doing great. GO FIGURE :chuckle

Coworker had one LOL who was very demanding all night, kept wanting to be repositioned. We moved her around the bed in microscopic degrees about q 15 minutes. By about 0330, we were getting a tad tired of the Princess & the Pea.
Finally, she began c/o GERD (and she had a hx of GERD) and nausea. She vomited a little. We got an EKG per protocol and tried some Mylanta because of her epigastric discomfort.
The EKG showed she was having an AMI. :uhoh21: I recall this so well because her s/s were so atypical.
We get a lot of "silent MIs" where I work partly because we deal with a population that is older and with lots of diabetics.
Most of the time, our younger CP folks are having some kind of pneumonia, a PE, or a problem with their gallbladder or an ulcer. I can't really tell the difference without labs, and I doubt anyone else can either. Which is why we joke about some patients coming to our ER. We kid that they could come in c/o being constipated and they'd start a CP r/o MI protocol because we're so hot on f/u of anything that remotely could be an MI.

Northernlights · Feb 3, 2005

I often say that the chest pain pt. coming into the ER by EMS saying "I'm having a heart attack" is more like not an acute coronory; and the patient walking in the front door of the hospital with chest pain that says, "I'm having chest pain, but I'm sure it's not my heart" probably is having an MI.

In my experience, there is either denial or a true sense of dread with MI patients.

CHATSDALE · Feb 3, 2005

use to work cardiac floor...all nurses carried ntg in pocket...if any c/o CP patient was given ntg plus a cocktail of various anti-gerd meds and given an ekg

listen to your patient..and not just the verbal words...if pt looks scared . bad sign .

candyndel · Feb 3, 2005

We have had similar cases to those. Except when we go back and look at the first 'normal' ECG, it is usually diagnostic, but unfortunately misread.