Remote Primary Health Care Manuals

Chest pain

  • Treat as serious and call for help. For initial assessment — see Acute assessment of chest pain

  • Get defibrillator, use as monitor

  • Only test needed to assess for thrombolysis is

    ECG

  • Always do full assessment

Many heart attacks are missed because symptoms not typical — especially in young adults, women and people with diabetes

Refer to your local regional Acute Coronary Syndrome Flowcharts if available

Initial management — all chest pain

Do first

  • Person on bed partly sitting up
  • Record time they arrived 
  • If they look very sick or are very distressed — call for help
  • Do 12 lead ECG immediately — urgent medical consult within 10 minutes
    • Leave leads on — will need to repeat
  • POC Test — troponin

Ask

  • Pain
    • Time it started
    • What it feels like
    • What makes it worse or better — movement, lying/standing, eating, breathing deeply
    • Does it move anywhere else
  • Other symptoms — fever, cough, difficulty breathing, nausea
  • Any injury related to pain
  • Allergies, medicines, other major health problems

Do

  • If short of breath, cyanosed (blue) or O2 sats low — give oxygen to target O2 sats 94–98% OR if moderate/severe COPD 88–92%. Avoid too much oxygen
  • Give aspirin oral single dose — adult 300mg — unless allergic
  • Put in IV cannula
    • Take 15mL blood (EDTA, coagulation studies and serum)
    • Flush with 5mL normal saline
  • If systolic BP more than 100mmHg and no contraindications give
    • Nitrate therapy
    • 250mL bolus of normal saline and assess response
  • If person still has pain — may need morphine IV — doses

Nitrate therapy

Do not 

  • Do not give nitrate therapy if systolic BP 100mmHg or less — check BP before each dose
  • Do not give nitrate therapy if person has used drugs for impotence
    • Sildenafil or vardenafil in past 24 hours
    • Tadalafil in past 2 days

Do

  • Give nitrate therapy sublingual (under tongue)
    • GTN spray — 1 puff
    • OR isosorbide dinitrate tablet — 5mg
  • If still pain after 5 minutes — give second dose of nitrate therapy
    • GTN spray — 2 puffs
    • OR isosorbide dinitrate tablet — 5mg
  • If still pain after 10 minutes — consider morphine IV — doses
    • If good effect and systolic BP still more than 100mmHg — can continue nitrate dosing every 5 minutes in addition to morphine

Assess for thrombolysis

For indications for thrombolysis — see Table 2.6

For contraindications for thrombolysis — see Table 2.7

Do first

  • Medical consult before giving 
  • Only give thrombolysis therapy (tenecteplase) to people with ST elevation myocardial infarction (STEMI) — Table 2.6
  • Always assess for contraindications​
  • Put in second IV cannula — 16G if possible

Obtaining consent

Explain to person there is no guarantee they are having a heart attack

  • Benefits — 2 lives saved for every 100 people 
    • Less damage to heart muscle
  • Risks — for every 100 people treated 
    • 3 people will have serious bleeding 

    • 1 person will have stroke, due to bleeding inside head

Table 2.6   Indications for thrombolysis

Pain

Chest pain that could be a heart attack

  • Lasted at least 20 minutes
  • Not relieved by nitrate therapy
  • Started less than 12 hours ago
AND
ECG

ST segment elevation

  • 1mm or more in 2 adjacent limb leads
    • 2 of — II, III, aVF OR both I and aVL
  • OR 2mm or more in 2 adjacent chest leads
    • 2 of — V1, V2, V3, V4, V5, V6

Table 2.7 Contraindications to thrombolysis

Always ask about these

Absolute
 Relative
  • Active internal bleeding — gastrointestinal or urinary
  • Head injury in past 3 months
  • Suspected aortic dissection (severe chest pain with stroke symptoms)
  • Known brain tumour or aneurysm
  • Taking anticoagulant (eg warfarin)
  • Procedures involving internal blood vessels — central venous line
  • Major surgery in past 3 weeks
  • Prolonged CPR — more than 10 minutes
  • Internal bleeding in past 4 weeks 
  • Chronic, poorly-controlled or severe high BP
  • BP more than 180mmHg systolic or 120mmHg diastolic on arrival
  • Stroke more than 3 months ago
  • Dementia
  • Pregnancy
  • Advanced liver disease
  • Transient ischemic attack (TIA) in preceding 6 month

Do

If ECG abnormal with ST elevation myocardial infarction (STEMI) AND positive troponin

If thrombolysis is indicated

  • Give enoxaparin IV single dose — 30mg
    • Do not give if over 75 years
  • AND give tenecteplase IV over 10 seconds — see Table 2.8 for doses

Monitor

  • BP every 5 minutes during thrombolysis, then every 15 minutes until transfer
  • ECG — 1 hour and 3 hours after thrombolysis or if arrhythmia

AND

For ALL ST elevation myocardial infarction (STEMI) AND ST depression OR T wave inversion with positive troponin (nonSTEMI)

  • Give enoxaparin subcut 1mg/kg/dose
    • If more than 75 year give 0.75mg/kg/dose
  • Give clopidogrel oral single dose — 300mg (4 tablets)
  • Give nitrate therapy and morphine for pain if needed
  • Check aspirin given

Monitor Pulse, O2 sats, continuous cardiac rhythm

For ST depression OR T wave inversion with negative troponin — angina

  • Give nitrate therapy and morphine for pain
  • Check aspirin given

Monitor

  • With heart monitor if available — continuous ECG, 15 minutes observations
  • Repeat ECG after 30 minutes and send to doctor
  • Repeat troponin test at 6 hours. If positive — medical/specialist consult

Table 2.8   Dose of tenecteplase IV

Weight
(kg)		 Tenecteplase IV (unit) Tenecteplase IV (mg) Volume
of reconstituted fluid (mL)
Less than 60kg 6,000 30mg 6mL
60–69kg 7,000 35mg 7mL
70–79kg 8,000 40mg 8mL
80–89kg 9,000 45mg 9mL
90kg or more 10,000 50mg 10mL

Follow-up

All people with angina or heart attack need careful follow-up to lessen risk of more heart disease