ED nurse initiated Rx of the adult patient presenting with chest pain

see also:

• EM nursing
• nurse initiated ED treatment
• ED nurse initiated analgesia
• Western Health policies (intranet only):
  • Nurse initiated procedures
  • Nurse Initiated X-rays
  • Nurse Initiated Intravenous Opioid Analgesia Standing Orders

• adult patients with chest pain usually require urgent initial assessment to exclude time critical conditions such as acute myocardial infarction (AMI/STEMI/NSTEMI)
• their time to diagnosis could be reduced and their symptoms partly relieved by nurse initiated ED Rx, although it is recognised that these presentations can be complex and warrant timely medical assessment to properly exclude important red flags.
• the following is a suggested framework for ED's who have nurses accredited to undertake ED nurse initiated treatment including the ordering of pathology tests and Xrays.

• see also: basic nursing assessment common to all pathways

• see also: the adult patient with chest pain in the ED

• ST elevation or LBBB on ECG
• cardiac arrhythmias
• hypotension (BP < 100mmHg)
• hypoxia (SaO2 < 92% room air)
• severe hypertension (BP > 180mmHg)

• eg. anterior chest pain in adults
• move to a cardiac monitored cubicle
• oral aspirin 300mg if not already had asprin that day
• oxygen but only sufficient to keep SaO2 > 96%
• 12 lead ECG
  • have this checked by a senior ED doctor ASAP to exclude STEMI or LBBB which may require urgent cardiology referral for possible angioplasty
• iv access
• bloods for FBE, U&E, glucose, CK, troponin, and other bloods as indicated:
  • INR if patient on warfarin
  • serum digoxin if on digoxin
  • D-Dimer (ask ED doctor BEFORE sending it) if PE is a better explanation and patient does not have any of the following:
    • age > 60 years
    • fever or recent infection
    • recent surgery or trauma
    • known current DVT
• if ongoing pain consider:
  • 1/2 anginine if BP > 120mmHg and patient has NOT used Viagra recently
  • iv morphine
  • if severe pain persists, urgent ED medical referral
• if BP is high, check BP in each arm as a difference may suggest aortic dissection
• CXR on cardiac monitor

• these patients could be considered for Mx in Fast Track without cardiac monitoring if clinically stable (not hypotensive, not hypoxic)
• iv access
• bloods for FBE, U&E and if pulmonary embolism (PE) is possible cause, consider D-Dimer after discussion with an ED doctor(see above for exclusions), and 12 lead ECG
• CXR looking for pneumothorax or pneumonia