📝ED #Order

▪️Imp: chest pain
▪️Cond: emergency
▪️Diet: NPO temporary
▪️Act: CBR and bed sides up

▪️CVS q4-6h
▪️CM and POM
▪️IV catheter fix

▪️ECG stat and then q15min (if initial ECG is nondiagnostic but clinical suspicion remains High)
🔺initial ECG often not diagnostic
▫️ECG be obtained within 10 min of presentation in ED
▫️ST-elevation or STEMI-equivalent (new LBBB, post STEMI, de Winter sign)
▫️A normal ECG does not exclude a life-threatening condition but makes the diagnosis of some (eg, ACS, stress cardiomyopathy) less likely.

▪️CXR portable (PA and Lat)
*The CXR may be diagnostic (eg, pneumothorax), but even in the presence of a life-threatening condition it may be normal (eg, ACS, PE) or have nonspecific findings(eg, atelectasis for PE).


▪️Check h.s Trop at 0 and 1, 2 or 3 hours
* اگه h.s نبود با توالی 0.3.6h میفرستیم
▫️a single set of negative trop is not sufficient to rule out AMI.
▫️cardiac trop I and T detect elevations within 2 to 3 hours, peak at 12 hours, and
remain elevated for 7 to 10 days.

▪️Check CBC, Bun, Cr,Basic electrolyte (Na, K, Mg, Ca),PT, PTT, INR.
*ESR, CRP, BNP and NT pro-BNP,LFTs, Bill T and D if needed and based on the condition
▫️some reasons :
▫️Anemia in a patient with exertional chest pain is suggestive of myocardial ischemia, but also consistent with aortic rupture.
🔺ABG is not routinely indicated for patients with chest pain.
▫️LFTs, lipase: helpful in patients with clinical suspicion for biliary tract disease or pancreatitis

▪️Oxygen therapy to maintain 90-94%

▪️ICU admission
▫️Any patient with hemodynamic instability or significant respiratory distress.

🔹Some consideration:

▪️Chest CT if indicated
▫️CT is the preferred in most ED patients with chest pain not suspicious for ACS who
require advanced imaging for diagnosis( aortic dissection, PE,rib fracture, etc)


▪️ Check D-dimer if indicated
▫️in patient with low-or moderate pretest probability for PE
▫️elevated D-dimer at baseline are those with advanced age, malignancy, sepsis, recent major surgery or trauma, or pregnancy
▫️D-dimer in combination with the Aortic Dissection Detection Risk Score (ADD-RS) may be useful to rule out suspected aortic dissection

▪️Bedside ultrasonography, if indicated
▫️esp in a patient with hemodynamic instability can identify pericardial effusions and tamponade, RV strain, etc.

▪️TTE if indicated
▫️Consider in suspected Myocarditis, pericarditis, pericardial effusion/tamponade, stress (takotsubo) cardiomyopathy

▪️CTPA( with contrast ) if indicated
▫️Consider in suspected PE

▪️M.S 2-4mg slow IV push if indicated (may be repeated q5-15 min as necessary)
▫️for severe, persistent chest pain that not relief by other medications
🔺m.s may worsen the outcome of AMI

🔹in suspected ACS

▪️Aspirin 162 to 325 mg (nonenteric coated) chewed and swallowed.
🔺In patient without concern for aortic pathology or GI perforation

▪️sublingual nitroglycerin tablets (0.4 mg) q5min up to 3 doses

▫️in patient with persistent chest discomfort, hypertension, or signs of HF
🔺be careful(or contraindicated)if there are sign of hemodynamic compromise (eg, RV infarction), severe aortic stenosis, HCM, hypotension, marked bradycardia or tachycardia and recent use of phosphodiesterase inhibitors (eg, Viagra)
▫️add IV nitroglycerin for persistent symptoms

🔹Appendix:

▪️Life-threatening causes:

•Acute coronary syndrome (ACS)
•Acute aortic dissection
•Pulmonary embolism
•Tension pneumothorax
•Pericardial tamponade
•Mediastinitis (eg, esophageal rupture)
•Myocarditis
•Stress (takotsubo) cardiomyopathy
•Perforated peptic ulcer

▪️Assume an ED patient with chest pain and any of the following has a lifethreatening condition until proven otherwise:

•Abnormal vital signs
•Obvious distress
•Signs of hypoperfusion (eg, diaphoresis, cool/clammy skin)
•Abrupt onset of thoracic or abdominal pain with a sharp, tearing, and/or ripping
•Variation in pulse (absence of a proximal extremity or carotid pulse) and/or blood pressure (>20 mmHg difference between the right and left arm)
•ECG with ST-Elevation