Management of Chest Pain and Shortness of Breath
Primary topic:
Initial management of patient with chest pain and acute shortness of breath
Secondary topics:
Management of acute myocardial infarction according to type and local protocols
Management of acute left ventricular failure
Curriculum mapping
Foundation programme 7.1 (Core skills in relation to acute illness)
Knowledge
Common presenting symptoms and signs of acute illness
Causes of chest pain
Clinical interpretation of acutely abnormal physiology
Safe oxygen therapy
Safe use of analgesia
Competencies
Promptly assesses the acutely ill or collapsed patient
Responds appropriately to abnormal physiology
Reassesses appropriately
Foundation programme 7.2 (Resuscitation)
Knowledge
Contents of advanced life support
Competencies
Able to initiate resuscitation at advanced life support level
Foundation programme 7.3 (Management of the “take”)
Knowledge
Indications for urgent investigations and therapy
When to seek help and from whom
Competencies
Able to prioritise
Interacts effectively with other health care professionals
Keeps patients and relatives informed
Receives and makes referrals appropriately
Delegates effectively and safely
Performs safe handover
Learning Objectives
At the end of this session the doctors should be able to:
In scenario role;
Confidently assess an acutely ill patient using the ABCDE approach
Recognise STEMI with LVF
Take a focused history
Initiate appropriate initial management
Apply STEMI protocol
Reassess after intervention
Appropriately handover to a colleague
In observation role;
Critique colleague performance
In debrief;
Discuss different approaches to the clinical problem
Discussion topics
Differentiation between NSTEMI and STEMI
Typical ECG appearances of NSTEMI / STEMI / LVF
Management of NSTEMI / STEMI / LVF according to local protocols
Use of tirofiban
Use of thrombolysis
Referral for angioplasty
Scenario
66 year old female just arrived via ambulance to ED. Past medical history of breast cancer (treated 5yrs previously) and hypertension. Takes aspirin, ramipril and tamoxifen. Works as a carer, current smoker 20/d with 30 PYH and a family history of IHD – father died 67 of MI. Presents with sudden onset 2hrs ago of cardiac sounding chest pain which came on at rest with associated dizziness and SOB. She was given oxygen, GTN and aspirin in the ambulance and is feeling a little better but still has some pain.
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STAGE |
EVENTS |
OBSERVATIONS / AVAILABLE RESULTS |
EXPECTED ACTIONS |
PROMPTS |
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Initial assessment
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F2 arrives to see the patient in a very busy department. A nurse is available but has not yet applied monitoring.
Patient is complaining of chest pain and is feeling short of breath. |
Sats: 95% on 02 Pulse: 100 BP: 145/78 RR: 26 Temp: 37.4
|
Introduces self Explains throughout to patient Asks for monitoring Takes focused but adequate history.
Airway: Assesses airway as patent
Breathing: Assesses respiratory rate and SaO2 Palpates, percusses and auscultates noting mild bilateral creps. High flow oxygen Sits up ABG
Circulation: Notes observations. Asks for cap refill time. Requests ECG. Inserts cannula and takes bloods |
Encourage to talk to patient and treat as would usually, if doesn’t take much history.
If they ask for observation but haven’t attached that monitoring prompt to do so.
If forgets bloods or ECG, nurse to ask “anything else?” but no other prompt – let scenario run. |
|
Initial management |
Patient is still complaining of chest pain and is feeling short of breath.
Patient is managed according to initial part of STEMI protocol and reaches the stage of consideration of primary angioplasty vs. thrombolysis at which point patient deteriorates. (Don’t let them thrombolyse before deterioration) |
Sats 96% on high flow O2 Pulse 104 BP 130/85 RR 26 Temp 37.3
ECG shows anterior ischaemia with ST elevation
ABG on 02 P02 – 13.9 PC02 – 4.9 HC03 – 21 BE - -2 Hb 11 Lactate 1.8
|
Recognises that requiring high levels of 02 to maintain oxygenation.
Requests portable CXR.
Recognises STEMI from ECG and symptoms. Suggests possible acute LVF also.
Manages according to initial part of attached STEMI protocol. Gives Frusemide in addition.
Assesses for primary angioplasty and makes clear referral to senior with all relevant information over phone. |
|
|
Reassessment * |
Patient more short of breath.
F2 could arrive at this point. |
BP 125/70 P 110 Sa02 91% on high flow 02 RR 30 Temp 36.8
|
Recognises deterioration. Assesses ABCDE
Airway – assesses as patent
Breathing – as previous Asks for repeat CXR.
Asks for further ECG.
Calls for help.
Calls for resus trolley. |
Nurse can prompt “She isn’t looking as well doctor.
If does not notice deterioration drop sats further.
If does nothing appropriate eventually patient arrests. |
|
Management of deterioration |
Patient remains more short of breath. |
BP 125/70 P 110 Sa02 92% on high flow 02 RR 30 Temp 36.8
CXR shows worsening LVF. |
Continues high flow oxygen.
Gives clear update of situation to seniors.
Considers treatment with nitrates and CPAP. |
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* At this stage depending upon progress the candidate could be encouraged to reassess even without patient deteriorating.