Situation
Chest pain is one of the most common ED presentations, accounting for between 5 and 8% of ED attendances in the US every year[1]. Chest pain can have numerous causes and it’s important for us to distinguish between the life threatening and the not-so-much. As an ED nurse your assessment of the patient may be the first they get so its important to get it right.
Background
Unfortunately not every patient with an acute myocardial infarction (MI) have the textbook history of “I have central crushing chest pain radiating to my left arm” (that would just be too easy wouldn’t it!).
As you can see from the infographic there are lots of underlying causes for chest pain. Some are immediately life threatening (and therefore in red, the universal colour of “this is bad”) so we need a system of narrowing it down.
As with most things in ED it’s common practice to assume the worst and work backwards, so we need to rule out the acute MI or pulmonary embolism (PE) as a matter of urgency.
Always remember to listen to your spidey-sense/gut instinct/gestalt… If the patient looks and feels like they’re dying that’s an important thing to recognise and you should get senior help immediately!
Assessment
There’s plenty of mnemonics out there to help you with your assessment so find the one that works best for you. We’re going to use PQRST here…
Provoke/Palliate- What was the patient doing when the pain came on? What makes it worse? Did it just come on out of nowhere, were they exerting themselves, were they sat doing nothing? Does anything help it? Have they taken analgesia and has it worked?
Quality- How do they describe the pain? Stabbing/twisting/burning? Does it feel tight? Did they feel sick? Were they sweaty or clammy at the time?
Radiation- Does the pain go anywhere else? Through to their back, into their jaw, down their arm?
Severity- What is the pain score out of 10? This is important to have as a baseline as you need to quantify if your analgesia has worked.
Timing- When did it start? Is it still there? If not how long did it last?
All of these factors in your history, as well as how the patient looks, can help narrow things down.
For example, if a patient has central chest pain radiating to their jaw whilst walking up stairs and they look grey and clammy, this sounds like cardiac chest pain. If a tall skinny young boy had sudden upper left sided chest pain whilst playing sport, it sounds like a pneumothorax. And so it goes on…
Its important to make sure chest pain patients have an ECG and full set of observations as soon as possible on arrival to the department. Ensuring and early ECG is taken can alert you and the team to any immediate life-threatening changes such as ST elevation, myocardial ischemia or signs of PE.
It may also be that you take bloods on arrival of your patient. In this case you should check your departments protocols as to what cardiac markers you include and at what time. The ‘routine’ bloods would include full blood count (FBC), urea and electrolyte’s (U&E’s) and liver function tests (LFT’s). If you suspect and infection then you may choose to add a CRP. If it sounds suspicious of a PE you may choose to add a D-dimer.
The easiest way to get to grips with this is by asking someone which bloods you think the patient needs, the more you ask the more you learn.
Recommendation
From here I’d recommend reading some further #FOAMed articles below…
For cardiac markers and ECG’s see Life in the Fast Lane…
https://lifeinthefastlane.com/ccc/cardiac-biomarkers/
This EMS world article goes into some more depth…
https://www.emsworld.com/article/10455093/chest-assessment
Hope this helps!
Liz xx
[1] https://bestpractice.bmj.com/topics/en-gb/301
[RCN Emergency Nurse Competencies: CCT 1.2.2, CD1 2.2.1 Levels 1 & 2]