"Atypical" patients may wait longer for EKGs

Listen carefully to patient's symptoms

A 28-year-old man was given an immediate EKG when he told ED nurses at Parkland Health & Hospital Systems in Dallas that he felt like someone was "holding my chest tight, like a band around my chest."

"There were no outstanding clues, just his story of substernal chest pain radiating down both arms," says Lillian Jones, RN, who cared for the patient, who had cardiac damage.

Cardiac patients who present with atypical symptoms, however, may wait longer for EKGs, says Jones. At Parkland's ED, all chest pain patients 35 years and older, diabetics, and those with a history of cocaine use or coronary artery disease have a set of stat vital signs and an EKG done. "This takes care of a high percentage of overall chest pain patients," she says.

However, you need to listen closely to what your patient tells you, to determine if a stat EKG is needed, says Jones.

"The classic presentation of chest pain, diaphoresis, shortness of breath, and an 'I'm going to die' look is easy to see,'" says Jones. "It's the patients that don't fit the above criteria that need thorough assessment."

Get description of pain

No matter what criteria you use to determine which patients should get an immediate EKG, you still have to rely on the patient's description of symptoms and how he or she looks, says Jones. Jones advises using "APQRST" to improve your assessment, as follows:

A= Associated symptoms.

"Dyspnea, and to a lesser extent weakness and fatigue, are big red flags," says Jones. Think of right coronary artery occlusion stimulation of vagal receptors if the patient reports vomiting and nausea, says Jones, and consider brady-tachycardia dysrhythmias if the patient is lightheaded or dizzy.

P = Precipitating factors.

Angina is often brought on by exertion, and angina at rest is a worrying factor, says Jones. "If the patient reports chest pain with deep inspiration, don't forget to ask about recent chest trauma," she adds.

Q = Quality. (See clinical tip, below, to get patients to describe their pain.)

R = Region, radiation, and risk factors.

"Pain in the medial aspect of the left arm often accompanies ischemic chest pain," says Jones. "Pain that is easily localized to a small area is rarely ischemic."

S= Severity.

"Ask the patient to rate the pain on a scale from one to 10," says Jones.

T = Timing.

Anginal pain is usually brief, lasting from five to 15 minutes, says Jones. "If the chest pain occurs 20 to 30 minutes after meals or is worse when lying down, it's usually [gastroesophageal reflux disease]," she adds.


For more information on which patients should receive an immediate EKG, contact:

  • Lillian Jones, RN, Emergency Services, Parkland Health & Hospital Systems, Dallas, TX. Phone: (214) 590-1144. Fax: (214) 590-2781. E-mail: L1JONE@parknet.pmh.org.

Clinical Tip

Instead of "pain," ask about "discomfort"

If you ask your patients to describe the chest pain they're experiencing, you may not get the information you're looking for. "This is usually very difficult for patients to describe," says Lillian Jones, RN, an ED nurse at Parkland Health & Hospital Systems in Dallas.

Jones says to use the word "discomfort" rather than "pain." "Don't prompt the patient," she advises. "Let them tell you in their own words what it feels like."