scgh ed chest pain pathway
TRANSCRIPT
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The Chest Pain Pathwayfor Acute Coronary Syndromes
Sir Charles Gairdner Hospital
Reviewed and agreed to by: HODs of Cardiology, Emergency Medicine,
Medical Assessment Unit, Clinical Biochemistry
2015, for review 2018Dr James Rippey
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SCGHEDCodeSTEMIProtocol
IsitanacuteSTEMI?
Pain<12/24
ECGchangesconsistentwithSTEMI• STelevation>1mmin2contiguouslimbleadsor• STelevation>2mmin2contiguouschestleads
Doesitmeetcriteriatoactivate“CODESTEMI”?
Inclusioncriteria• Symptomonset<12hours• <85years• Ongoingpain• Mobileandindependent
Exclusioncriteria–fordiscussion
• >85years• LBBB• PriorCABG• Significantcomorbidities• Outofhospitalcardiacarrest• Pulmonaryoedema• Cardiogenicshock• Recentmajorsurgery(<2/52)• Activebleeding
EDconsultant/nightSRdiscusswithon-callGeneralCardiologist
(notcardiologyregistrar)
Isprimaryinterventionappropriate?
MedicalManagementEDconsultant/nightSR
DIAL55State“CODESTEMIEDnow”
Activate“CODESTEMI”whereappropriate
PatientpreparationinED
· Aspirin 300mg
· Ticagrelor 180mg or o If contraindicated
Prasugrel 60mg or
o If contraindicated
consider Clopidogrel
600mg
· Heparin 5000 IU IV
· Prepare for transfer
ContraindicationstoP2Y12inhibitors· Active bleeding
· Allergy
Ticagrelor:· Heart rate <50 bpm
· Chronic dyspnoea
· History ICH / TIA / Stroke
Prasugrel:· Weight < 60kg
· Age > 75 yrs
· History ICH / TIA / Stroke
Clopidogrel
· History ICH
TransfertoCathLab(CVIL)
NoYes
Suitableforrapidtransfer· Transfer with ED RN and ED Dr
· Work hours 0730-1700, transfer
without delay
· After hours, transfer 10 minutes
after Code STEMI activation
· Record time of arrival on ECG
· ED staff to stay with patient
until appropriate CVIL team
members arrive
Notsuitableforrapidtransfer· Notify cardiology registrar
· Remain in ED until appropriate
CVIL team members arrive and
call for patient
· Transfer to CVIL with ED RN
and cardiology registrar
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SirCharlesGairdnerHospitalEmergencyDepartment
ChestPainDischargeAdviceSheet
LowRiskAcuteCoronarySyndromeGroup
YouhavebeenreviewedintheEmergencyDepartmentatSirCharlesGairdnerHospitalafterpresentingwithchestpain.Afterconsideringyourhistory,yourriskfactors,yourECGandyourbloodtests(troponin),youhavebeenfoundtobeatverylowrisk(around1in100)ofhavingamajoradversecardiacevent(likeaheartattack)inthenearfuture.Inthe“lowrisk”group,therisksofdoingfurthertestsandtreatmentasaninpatientoutweighthebenefits.Inmanypatientsinthelowriskgroupfurthertestsofanysortareunnecessary,howeveryoushoulddiscussthisfurtherwithyourgeneralpractitionerwhowillunderstandyourmedicalandpersonalbackgroundbetter.Becausewecanneverdeclareyouat“norisk”wewouldsuggest:
1. Returningformedicalreviewifyouhavefurtherepisodesofchest/armpainorotherconcerningsymptomslikedizziness,collapse,palpitationsorshortnessofbreath
2. Followingupwithyourlocaldoctorwhoconsidertheneedforfurthertestingandwillalsoensurethatanymodifiableriskfactorsyoumayhaveforheartdiseaseareoptimallymanaged.Thesemayinclude:
i. Stoppingsmokingii. Treatinghighbloodpressure
iii. Managinghighcholesterolleveliv. Managingdiabetesv. Increasingexerciseandmanagingyourdiet
IfyouhavefurtherquestionsaboutwhatthismeanspleasediscusswiththedoctorslookingafteryoubeforeyouleavetheEmergencyDepartment,orwithyoulocalgeneralpractitioner.
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SirCharlesGairdnerHospitalEmergencyDepartment
ChestPainDischargeAdviceSheet
LowRiskAcuteCoronarySyndromeGroup
YouhavebeenreviewedintheEmergencyDepartmentatSirCharlesGairdnerHospitalafterpresentingwithchestpain.Afterconsideringyourhistory,yourriskfactors,yourECGandyourbloodtests(troponin),youhavebeenfoundtobeatverylowrisk(around1in100)ofhavingamajoradversecardiacevent(likeaheartattack)inthenearfuture.Inthe“lowrisk”group,therisksofdoingfurthertestsandtreatmentasaninpatientoutweighthebenefits.Inmanypatientsinthelowriskgroupfurthertestsofanysortareunnecessary,howeveryoushoulddiscussthisfurtherwithyourgeneralpractitionerwhowillunderstandyourmedicalandpersonalbackgroundbetter.Becausewecanneverdeclareyouat“norisk”wewouldsuggest:
1. Returningformedicalreviewifyouhavefurtherepisodesofchest/armpainorotherconcerningsymptomslikedizziness,collapse,palpitationsorshortnessofbreath
2. Followingupwithyourlocaldoctorwhoconsidertheneedforfurthertestingandwillalsoensurethatanymodifiableriskfactorsyoumayhaveforheartdiseaseareoptimallymanaged.Thesemayinclude:
i. Stoppingsmokingii. Treatinghighbloodpressure
iii. Managinghighcholesterolleveliv. Managingdiabetesv. Increasingexerciseandmanagingyourdiet
IfyouhavefurtherquestionsaboutwhatthismeanspleasediscusswiththedoctorslookingafteryoubeforeyouleavetheEmergencyDepartment,orwithyoulocalgeneralpractitioner.
Low risk
GP consider further investigation
Come back if concerns
Manage risk factors
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Feedback:
Dr James RippeyCall via switchboard