Your ED's next acute MI patient might not be what you're expecting

Symptoms are cardiac, 'until proven otherwise'

Several years ago, walking through the waiting room at Baystate Medical Center in Springfield, MA, on her way to triage, Ellen Smithline, RN, CEN, TNCC-I, ENPC-I, an ED clinical educator, noticed a woman in her 30s who looked pale and was rubbing her chest.

"Her body posture was tense," Smithline recalls. "I walked over to her to ask if she was OK."

The only symptom the woman reported, however, was "not feeling right" and a problem catching her breath. She denied having any chest pain, pressure, or tightness, and knew of no family history of cardiac problems. Despite this, Smithline brought her back to be reassessed.

"Her vital signs were normal, but she just didn't look right. I immediately took her in, and I am glad I did," she says. "Shortly thereafter, the ED team was administering thrombolytics to her due to an AMI. Today, she would have been on her way to the cardiac catheterization lab."

Richard Body, MD, an ED physician at Manchester (England) Royal Infirmary, says if all your patient can tell you is that she's not feeling right, "you certainly still can't rest easy. You have to presume they could have ACS [acute coronary syndrome] until proven otherwise."

Of 796 patients presenting to Body's ED with suspected cardiac chest pain between January 2006 and February 2007, 148 were diagnosed with AMI, according to his just-published research.1 Some "typical" symptoms had no diagnostic value at all, discovered researchers, while some "atypical" symptoms were more common than expected. Pain radiating to the right arm or both arms, vomiting, central chest pain, and sweating all made AMI more likely; whereas pain in the left anterior chest made AMI significantly less likely.

"We're all aware of practitioners who will suggest that they are able to confidently exclude ACS on the basis of the patient's symptoms alone," says Body, the study's lead author. "This study presents good evidence to refute that."

Not every MI patient comes in with the "movie heart attack — the patient that comes in grabbing their chest, looking pale, dusky, and diaphoretic," says Smithline. "Life would be so simple as a triage nurse if everyone were that obvious. Unfortunately, that is not so." Since you probably are the patient's initial contact, remember that "heart disease is still the No. 1 killer of all ages, and it should not be taken lightly. If an AMI is not detected, it can lead to death," emphasizes Cathy C. Fox, RN, CEN, CPEN, clinical nurse educator for the ED at Sentara Virginia Beach (VA) General Hospital.

Here are things to consider if you suspect AMI, based on the study's findings:

• If a patient reports atypical pain such as having a pleuritic nature, burning or indigestion-like, or even a right-sided location, don't rule out ACS.

"In fact, some 'atypical' symptoms even render the diagnosis of ACS more likely — for example, radiation of the pain to the right arm," says Body.

• Remember that a longer pain duration makes an ACS diagnosis more likely, but there is no time frame below which ACS can be excluded.

"Some patients with a pain duration of five minutes or less were, in fact, having an AMI," says Body. "Therefore, if there are other features that make ACS a possibility, or if you can't otherwise explain the symptoms, the patient needs investigation for ACS. At the least, that means arranging for troponin testing and a serial EKG."

Fox says in her experience, with AMI pain:

— Chest discomfort usually will last longer than a few minutes, but it might come and go.

— Patients might report intense pressure, a vise-like grip, or a feeling of fullness.

— Pain might radiate into the neck, arm, back, abdomen, or jaw.

• If there's no apparent alternative cause for chest pain, give an immediate EKG.

Body emphasizes that the absence of EKG ischemia doesn't exclude ACS, unless an alternative cause is clearly established. However, he says, "the presence of EKG ischemia is, by far and away, the strongest early predictor of the patient's diagnosis and prognosis. Therefore, when seen, these changes should be considered to automatically identify the patient as high risk."

Reference

  1. Body R, Carley S, Wibberley C, et al. The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes. Resuscitation 2010; 81:281-286.

Sources

For more information on assessment of acute myocardial infarction in the ED, contact:

  • Cathy C. Fox, RN, CEN, CPEN, Emergency Department, Sentara Virginia Beach (VA) General Hospital. Phone: (757) 395-8954. E-mail: ccfox@sentara.com.
  • Victoria Leavitt, RN, MSM, Regional Nurse Educator, Education Services, Franciscan Health System, Tacoma, WA. Phone: (253) 426-6128. E-mail: victoria leavitt@fhshealth.org.
  • Tracy Simmons, RN, BSN, CEN, Clinical Educator, Emergency Department, OSF St. Francis Medical Center, Peoria, IL. Phone: (309) 655-4103. E-mail: tracy.a.simmons@osfhealthcare.org.
  • Ellen Smithline, RN, CEN, Clinical Educator, Emergency Medicine, Baystate Medical Center, Springfield, MA. Phone: (413) 794-8161. E-mail: Ellen.Smithline@baystatehealth.org.

Is it an AMI or not? Get the whole story

A full, thorough assessment can shed light on whether your patient's chest pain is due to muscle aches, gastric reflux, illegal drug use, or an anxiety attack.

"Get a story of how the pain started and what other symptoms the patient is having along with their chest pain," says Tracy Simmons, RN, clinical educator for the ED at OSF St. Francis Medical Center in Peoria, IL.

Simmons says when a woman presents with unusual or vague symptoms, you should work her up as a cardiac patient "until proven otherwise." To improve your assessment, do the following:

• Remember that although shortness of breath initially might appear to be a respiratory problem, it might be due to pressure being exerted on the cardiac muscle.

If your patient presents with an elevated respiratory rate, examine the patient's color and skin, says Cathy C. Fox, RN, CEN, CPEN, clinical nurse educator for the ED at Sentara Virginia Beach (VA) General Hospital. "Often, that gray or ashen appearance is a telltale sign that the heart is not getting enough oxygen," Fox says. "The skin will often become so moist and diaphoretic that clothing is drenched with sweat." [The documentation tool used by ED nurses is included. For assistance, contact customer service at (800) 688-2421 or customerservice@ahcmedia.com.]

• When in doubt, triage up.

Victoria Leavitt, RN, MSN, regional nurse educator and former ED nurse at Franciscan Health System in Tacoma, WA, says this statement about triage is always true, but is especially important when you suspect a cardiac event. "Women typically wait longer to come to an ED when having ACS [acute coronary syndrome] and are unfortunately not treated as aggressively as men," Leavitt says. "Do not make them wait any longer."

• Put the total picture together.

It is one thing for a young adult with no past medical history to tell you that he or she feels weak, unwell, and a bit dizzy. "It is a completely different issue when a diabetic tells you this," says Leavitt. "That diabetic may be having a cardiac event. Autonomic nervous system dysfunction may preclude exhibiting the classic symptomology."


Clinical Tip

Suspect cardiac pain? Use the right words

If your patients answer "no" when you ask if they have chest pain, it might be because they have a different word in mind. Patients often are waiting to hear "those specific words that describe their symptoms," says Ellen Smithline, RN, CEN, TNCC-I, ENPC-I, an ED clinical educator at Baystate Medical Center in Springfield, MA.

For this reason, Smithline uses these words: "Are you having chest pain, pressure, tightness, fullness, or a feeling that is different in your chest or anywhere else in your body?"

"How many times have you just stepped away from a 'pain-free' patient, only to find out that the next person interviewing them identified that they had been having chest pressure?" asks Smithline. "When approaching the patient about the change, they say, 'You didn't say 'pressure.' I believe patients become very 'literal' when they are in a stressful situation."


You can learn this from a quick look

Tracy Simmons, RN, clinical educator for the ED at OSF St. Francis Medical Center in Peoria, IL, says that an "across-the-room" assessment can tell you a lot about whether your patient might be having a myocardial infarction (MI).

"Patients who are having an MI have a certain look about them: They are usually quiet, anxious, ashen, and diaphoretic," Simmons says. "Look at their coloring, work of breathing, and anxiety level. These are all huge signals that something is amiss with this patient."

On the other hand, don't be misled by the patient that "looks too good" to have an MI. Victoria Leavitt, RN, MSM, regional nurse educator and former ED nurse at Franciscan Health System in Tacoma, WA, says, "Listen to their story, have an open mind, and put the diagnostic picture together." A 55-year-old man came to Leavitt's ED at 3 a.m. and complained of his arms and back hurting him. He had been moving furniture all day, but the man also looked anxious.

"He kept repeating that he did not like hospitals. And yet he was here, at 3 a.m.," says Leavitt. "When I took his pulse, I could feel he was ever so slightly diaphoretic. It was a hot summer night. It could have been nothing. But I brought him straight back, and his EKG showed significant ST elevation in all his anterior leads."

Years ago, when Leavitt was new in the ED, a middle-aged woman complained of bad indigestion. Because she looked pale and anxious, Leavitt brought her back to a room immediately and ordered an EKG. However, the ED physician canceled it and instead ordered a gastrointestinal cocktail, which relieved the burning sensation.

"She was sent home, and I felt foolish that I had overreacted. She came back several hours later as a full arrest," says Leavitt. "Had I been more experienced, I would have been vociferous in advocating that she get that cardiac work-up."