Guidelines for ED Observation of Chest Pain

TRANSFER CRITERIA

  • Clinical suspicion that risk of myocardial infarction is less than 6% (see Goldman algorithm).1
  • Chest discomfort is potentially cardiac ischemia (Based on risk factors / discomfort)
  • Normal electrocardiogram, or concurrence with cardiologist/private medical doctor
  • Acceptable vital signs
  • No history of known coronary artery disease, or concurrence with cardiologist/private medical doctor

EXCLUSION CRITERIA

  • Clinical suspicion that risk of myocardial infarction is more than 6% (see Goldman algorithm)
  • Electrocardiogram which shows evidence of myocardial infarction or clearly acute injury/ischemia pattern
  • Unstable vital signs
  • Clear unstable angina by history (i.e. known coronary artery disease, symptoms like prior angina/ myocardial infarction)
  • Chest pain is clearly not cardiac ischemia
  • Private attending chooses inpatient admission

INTERVENTIONS

Initial emergency department intervention:

  • IV (heplock?), oxygen, Telemetry Monitor System hook up, initial electrocardiogram, chest X-ray, NO caffeine.
  • If not contraindicated, give aspirin 325 mg by mouth, (consider Maalox 30 cc by mouth).
  • Appropriate nitrates (physician discretion) — Nitroglycerine SL prn, Nitro Paste, or Nitrobid.
  • Send initial biomarker(s) — Creatinine phosphokinase (CPK-MB), possibly Myoglobin or Troponini.
  • Emergency attending physician speaks with primary medical doctor or chest pain center cardiologist, choose stress test option.
  • If appropriate, Resting Cardiolyte Injection. Scan if feasible (i.e. time of day).

Emergency department observation unit interventions:

  • Call lab to add myoglobin to initial blood drawn in Emergency Center
  • Continue IV (heplock), oxygen, Telemetry Monitor System (ST segment) Monitor, Nitrates, No caffeine.
  • Send patient to obtain initial resting scan if ordered.
  • Perform electrocardiogram based on clinical suspicion or electrocardiogram "ST segment" monitor alert. Show Emergency Attending Physician/Physician Assistant stat.
  • Protocol = Time 0- and 4-hour electrocardiogram, MB isoform creatine kinase enzyme (CK-MB), and Myoglobin

If all tests are negative => appropriate stress test
If abnormal CK-MB or Electrocardiogram => admit IF:

  • (a) No stress test planned,
  • (b) ONLY myoglobin is elevated,
  • (c) 0 to 4hr CK-MB /Myoglobin doubled, or
  • (d) four-hour tests are missed:

Time eight-hour Electrocardiogram, CK-MB, Troponin T IF

  • If all tests are negative => appropriate stress test
  • If abnormal CK-MB, Troponin T, or Electrocardiogram => admit

DISPOSITION

Home —

  • Acceptable vital signs
  • Normal biomarkers
  • Unremarkable stress test
  • No significant electrocardiogram changes

Hospital —

  • Unstable vital signs
  • Positive biomarker
  • Electrocardiogram changes
  • Significant stress test abnormality
  • Emergency attending physician/private medical doctor clinical discretion

1/17/01

REFERENCE

1. Goldman L. Prediction of the need for intensive care in patients who come to the emergency department with acute chest pain. N Engl J Med 1996; 334:1,498-1,504.

Source: William Beaumont Hospital, Royal Oak, MI.