Hospital Standards for Accreditation for Afghanistan
Section 2: Clinical Care
Emergency Department:
Acute Chest Pain Syndromes
Hospital Standards for Accreditation for Afghanistan:
Assessment of Progress in Achieving the Standards
Hospital Department or Area:
Emergency Department: Acute Chest Pain Syndromes
Hospital Facility: ___________________________________
Assessor: __________________________
Standard
Number
Standard
1
Recognize that
atraumatic chest pain
has many causes and
many variable
presentations
Date of Assessment: ________________
Emergency Department: Acute Chest Pain Syndromes
Criteria for Verification of Meeting Standard
Compliance in
Meeting Standard
Full Partial None
2
1
0
Clinical Features:
- Consider variety of presentations or
symptoms of patients with myocardial
ischemia
- Where is the pain located: retrosternal,
epigastric, right or left chest, etc.?
- Is there anything that makes the pain
change in quality? For example, does
the pain change with inspiration, with
rest, with supine position, etc.?
- When did the pain begin? How long
does it last when it occurs?
- Are there any other associated
symptoms such as nausea, vomiting,
diaphoresis, dyspnea, weakness,
headache, etc.?
-
2
3
Does the pain radiate anywhere? For
example, does it radiate to the jaw,
neck, arm, abdomen, back?
- How is the pain described? Is it
throbbing, burning, sharp, stabbing,
dull, squeezing, etc.?
- Does the patient have any coronary risk
factors such as hypertension, known
coronary artery disease, tobacco use,
high cholesterol, obesity, diabetes
mellitus? Is the patient male? Is there
a family history of heart disease?
Recognizes that
- How does the patient look?
physical examination - What are the vital signs? Is the patient
may vary in patients
tachycardic, dyspneic, febrile,
with chest pain
hyper/hypotensive, hypoxic?
- Do you note rales, wheezing, rhonchi?
- Is there a murmur present?
- Is there any chest wall tenderness?
Rapid, quick
EKG: the ekg is quite clinically reliable and
assessment is
diagnostic in patients with acute infarctions
performed and early
- Is an EKG completed within 10
treatment is initiated
Minutes of a patient presenting to the
ED?
- Recognize that a normal ekg does not
rule out cardiac ischemia
- Are there ST elevations, Q waves, T
wave inversions, new bundle branch
blocks which suggest ischemia?
Serum Markers: If available, serum markers
are very specific for acute myocardial
infarction (AMI).
- A CK, CK-MB and troponin were
obtained shortly after patient arrival.
- Serial enzymes were evaluated because
these markers do not rise immediately.
- Time of symptom onset is known to
allow the physician to evaluate cardiac
enzyme results.
- Is aware that CK generally rises within
4-8 hours of an AMI and remains
elevated for several days. CK-MB
which is more specific to myocardium
typically rises within 2-6 hours of an
AMI and returns to normal within 1224 hours. Troponin is even more
specific and rises within 4-6 hours of an
AMI and remains elevated for up to 10
days.
Echocardiogram: May be helpful in
evaluating a patient with a normal ekg.
- Notes wall motion abnormalities are
suggestive of acute or previous
myocardial injury.
- Realizes that echocardiogram
examination may assist in diagnosing
pericarditis, aortic dissection and other
acute chest pain processes.
Oxygen/Monitoring/IVs:
-
Any patient suspected of having acute
cardiac pain is placed on continuous
cardiac monitoring, has an IV placed
and receives supplemental oxygen.
Aspirin:
- Aspirin 325 mg is given to any patient
suspected of having acute ischemia
unless there are contraindications.
4
Considers causes of
chest pain and is
aware of their
presentations and
immediate treatment.
Angina Pectoris:
- Is aware that this is often described as
squeezing or aching and usually lasts
less than 15 minutes.
- Realizes that this is usually episodic in
nature, relieved by rest or sublingual
(SL) nitroglycerin (ntg). NTG typically
relieves anginal pain in less than 3
minutes.
- Understands the difference between
stable and unstable angina. Unstable
angina is much more concerning due to
increased risk of sudden cardiac death.
Acute Myocardial Infarction/Acute
Coronary Syndromes:
Is aware that:
- Pain may not be relieved by ntg.
- May be accompanied by nausea,
vomiting, diaphoresis, radiation to jaw
or arm
-
Patients with diabetes mellitus, the
elderly, women and others may present
with very atypical symptoms.
Performs the following:
- Ensures patient placed on monitor,
receives O2 and an IV. Obtains an ekg
within 10 minutes of arrival.
- Gives the patient 325 mg aspirin to
chew (unless contraindications).
- Obtains a complete set of vital signs
immediately.
- Gives SL Ntg if considering AMI,
angina or ischemia.
- Is aware that Ntg may cause headache
in patients. Is aware that Ntg may
decrease blood pressure and is prepared
to counteract this.
- Understands that Ntg is contraindicated
in patients with Right Ventricular (RV)
infarction.
- Considers the use of IV beta blocker to
treat MI, hypertension, recurrent
ischemia, tachycardic rhythms, etc.
- Understands contraindications to beta
blockade: asthma, bradycardia,
hypotension, severe CHF, COPD,
severe peripheral vascular disease.
- Considers pain treatment with IV
morphine. Understands that this may
worsen hypotension.
-
-
-
Considers heparin therapy.
Considers fibrinolytics as appropriate.
Understands fibrinolytic relative and
absolute contraindications.
Recognizes RV infarcts and the need
for intravascular volume/elevated RV
filling pressures.
Admits patients with unstable angina,
acute myocardial infarction and
continues treatment and cardiac
monitoring.
Aortic Dissection:
- Considers in any patient who presents
with acute onset, severe, tearing or
ripping pain that is retrosternal and/or
radiates to the back. The pain is usually
maximal at onset.
- Recognizes that nausea, vomiting and
Diaphoresis may also be present.
- Obtains immediate vital signs,
including blood pressures in all four
extremities.
- Obtains an immediate chest xray and/or
CT scan if the patient is
hemodynamically stable.
- Immediately stabilizes the patient,
obtains large-bore IV access.
- Obtains abo/rh and cross match.
- Manages hypertension appropriately
with beta blockers IV or calcium
-
-
channel blockers (2nd line). Titrates to
pain relief and systolic blood pressure
of 100-120 mm Hg.
Understands the classification of aortic
dissections and the treatments of each.
- Stanford A: involves ascending
aorta and is typically treated surgically.
- Stanford B: involves descending
aorta and is most often medically
managed.
Places appropriate consults to
cardiology, vascular or thoracic
surgery.
Pericarditis: Acute pericarditis may be
difficult to distinguish from other causes of
chest pain.
- Recognizes that pain may be acute or
gradual in onset. It may radiate to the
back, left arm, neck or jaw.
- Is aware that symptoms may be
increased when supine and relieved
when leaning forward.
- Recognizes a friction rub heard at the
left lower sternal border or apex as
indicative of pericarditis.
- Knows that pericarditis may be
associated with fever and dyspnea.
- Can name etiologies of pericarditis
including viral, autoimmune, bacterial,
fungal, malignancy, drugs, radiation,
-
-
-
uremia, myxedema, idiopathic, etc.
Orders an ekg immediately and
recognizes changes that may occur with
acute pericarditis, including: diffuse
ST segment elevation early (this may
resolve), diffuse T wave inversion, PR
depression in inferolateral leads, etc.
Obtains a chest xray to rule out other
causes of pain.
If available, obtains an echocardiogram.
If the diagnosis is pericarditis and the
patient is stable, treats with
nonsteroidal anti-inflammatory.
Admits patients with pericarditis of
presumed uremic origin or any patient
who is unstable.
Pericardial Tamponade: May be traumatic
or nontraumatic in origin.
- Immediately places patient on monitor,
Oxygen, IV.
- Immediately obtains ekg.
- Recognizes etiologies as trauma,
malignancy, idiopathic, bacterial,
uremia, chronic pericarditis, TB,
collagen vascular diseases, etc.
- Notes symptoms consistent with
Tamponade, including dyspnea,
positional or pleuritic chest pain.
- Is aware of physical examination
Findings such as tachycardia, JVD,
-
-
-
hypotension, muffled heart sounds, etc.
Recognizes pulsus paradoxus (on
Inspiration 10 mm Hg decrease in SBP)
as a sign of tamponade or constrictive
pericarditis.
Recognizes electrical alternans (beat to
beat variability of QRS amplitude) as
an indicator of tamponade.
Performs immediate pericardiocentesis
if patient is critically unstable.
Prior to pericardiocentesis, gives 1 L
Crystalloid fluid bolus to improve right
heart filling (if time permits).
Pulmonary Embolism: A high index of
suspicion must be used for this diagnosis
given its nonspecific symptoms and variable
presentation.
- Immediately obtains EKG.
- Immediately places patient on monitor,
IV, O2. Begins IV crystalloid fluid
infusion to correct hypotension.
- Recognizes that symptoms may include
dyspnea, chest pain, tachycardia,
hypoxia, syncope, tachypnea, etc.
- Recognizes potential causes as
malignancy, hypercoagulable states,
venous stasis (trauma, post-operative,
sedentary/paralytic), pregnancy, etc.
- Immediately obtains chest xray to rule
out other causes of chest pain.
-
-
-
-
Orders blood tests including cbc,
electrolytes, coagulation studies,
creatinine, cardiac enzymes (if
available).
If available, orders CT scan of the chest
to further evaluate for PE size and
distribution.
Begins anticoagulation therapy. This
may be heparin or low molecular
weight heparin as available.
If hemodynamically unstable, considers
treatment with thrombolytics.
Recognizes other causes of acute chest pain
and potential presentations as noted in
attachment (1). These include pulmonary,
musculoskeletal and gastrointestinal causes.
DIFFERENTIAL DIAGNOSIS OF CHEST PAIN
AMI
Pericarditis
Angina
CHF
Aortic Dissection
Severe, nausea/vomiting, shortness of breath, diaphoresis,
Radiation to jaw or arm, Lasts more than 15 minutes
Positional pain, dyspnea, Symptoms relieved by sitting forward
Associated with exertion or change in stable angina
Dyspnea, Paroxysmal nocturnal dyspnea, Orthopnea, Peripheral Edema, JVD
Maximal at onset, ripping, radiates to back
May have altered mental status/loc
Pulmonary Edema
Bronchitis
COPD
Pulmonary Embolism
Pneumonia
Dyspnea, Tachycardia, Exertional symptoms, Paroxysmal Nocturnal Dyspnea
Cough, dyspnea, +/- Fever
Chronic cough, dyspnea
Acute onset, dyspnea, pleuritic pain, tachycardia
Fever, Cough, Dyspnea, Chills
Gastritis
Esophagitis
Esophageal Rupture
Splenic Rupture
PUD
Burning, often worse after eating
Burning, often worse after eating, may have dysphagia
Retrosternal or epigastric pain after vomiting/trauma
TTP, hypotension, tachycardia, Kehr sign
Abdominal pain, burning, +/- hematemesis, melena
Cholecystitis
Cholangitis
Pancreatitis
RUQ or R chest pain, often follows fatty meal, nausea/vomiting
RUQ pain, nausea/vomiting, fever
RUQ or midabdominal pain, nausea/vomiting
Costochondritis
Trauma
Not always inciting event; tender to palpation, symptoms increase with movement
YOU MUST ASK:
History:
Onset of symptoms;
description
Pain: where, what,
radiation
Other six: diaphoresis,
dizziness, syncope, fever,
cough, shortness of
breath
Past Medical History:
COPD, Trauma, DM,
Hypertension, CHF,
Hyperlipidemia
Family History: AMI
(age, sex),
Medications: