CHEST PAIN

1. Chest pain – must say whether this is 1st episode/ No history of angina attack. DO NOT
SAY no h/o heart diseases.

2. Myocardial ischaemia → Seen in elderly, in uncontrolled hypertension/DM and smoker. It

doesn’t always show a typical type of chest pain especially in female.

3. Cardiac (30%) vs Non Cardiac (70%)

4. Unpaired organ (heart, trachea, oesophagus, stomach, gall bladder, appendix, etc ) → Pain
starts in the midline

5. NOT MI:
 Localized pain and tenderness (The more likely the patient can pin point the pain,
the more unlikely it is of cardiac origin)
 More away from the center
 1st to consider – Oesophageal causes

6. GERD : Burning pain slightly relieved by leaning forward

Costochondritis: At the costochondral junction near the sternum
Aortic Dissection: Pain dominantly at upper back, can radiate to arm and abdominal pain.
7. Obese, with DM and Hypertension, and a smoker → If the ECG is normal → Repeat the
ECG ( 4x in 2 hours) → Insert a branula → give Aspirin

8. Unstable angina classification:

 New onset of severe angina or accelerated angina; no rest pain
 Angina at rest within past month but not within preceding 48 hours (angina at rest,
subacute)
 Angina at rest within 48 hours (angina at rest, acute)

9. Pre-hospital management
 If history suggestive of ACS:
- Give soluble aspirin 300mg
- Give sublingual GTN (unless SBP<90 mm Hg)
- Do 12 lead ECG & cardiac biomarkers
 If ECG & cardiac biomarkers suggestive of ACS:
- Give clopidogrel 300mg
- Send patient for definitive treatment
 If ECG and Cardiac biomarkers are inconclusive:
- Low risk patient: outpatient cardiac assessment
- Intermediate/high risk: admission

10. 3 types of patient in ED

1. Very low BP, very low pulse rate: complete heart block, need urgent pacemaker
2. Low BP, pulse rate tachycardia: Left ventricular failure, cardiogenic shock
3. BP and pulse rate acceptable

11. Clinical features of myocardial infarction

- Central, crushing chest pain
- Radiates to left jaw, teeth and left arm
- Associated with nausea, vomiting and breathlessness

12. Once diagnosed as coronary artery disease

 - Give aspirin 300 mg, make them chew and watch them swallowing
- Set branula
- Give GTN
- Do ECG : look for ST elevation :
STEMI : Give streptokinase (ONLY STEMI GIVE)
*Not given if chest pain >12 hours unless the pain persists or restarts
NTSEMI ( No ST elevation, Cardiac biomarkers elevation): give Fondaparinux
Unstable angina (No ST elevation, No Cardiac biomarkers elevation)

13. Streptokinase : TIME= MYOCARDIUM

Indication :
-STEMI

Absolute contraindication of streptokinase:

-History of intracranial bleeding
-History of ischemic stroke within 3 months
-Active bleeding like peptic ulcer disease and per rectal bleeding EXCEPT Menses
-Head trauma within 3 months

Relative contraindication of streptokinase :

-Uncontrolled HTN : give IV GTN
-INR>2
-Recent GI bleed (Active peptic ulcer)
-Recent major surgery
-Traumatic/ Prolong CPR >10 min

Complications of streptokinase :
-Bleeding : GIT, GIU
-Hypotension
 -Allergic reaction , fever, shivering, difficulty in breathing, periorbital swelling,
urticarial , nausea, itching
-Anaphylatic shock

Cardiac biomarkers : Troponin T not elevated in <6hrs (so repeat after 6 hours)

ACLS Algorithm