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Chest Pain


Chest Pain is the most well studied of any EDOU obs protocol.



Inclusion Criteria

  • ACS risk is low based on Reilly-Goldman(external link) criteria
  • Chest discomfort is potentially due to cardiac ischemia
  • No acute ECG changes of ACS, negative initial troponin (<0.04 or <0.15 if very low suspicion of ACS)
  • Acceptable vital signs


Exclusion Criteria

  • Moderate to high risk criteria by Reilly / Goldman criteria (Pain worse than usual angina or like prior MI, recent *revascularization, SBP<110, rales above both bases).
  • New ECG changes consistent with ischemia
  • Positive troponin (>0.15) not known to be chronic
  • Stress test or cardiac imaging needed - but NOT available while in the CDU
  • Chest pain is clearly not cardiac ischemia
  • Recent normal cardiac catheterization (no coronary stenosis)
  • Private attending chooses hospital admission

Potential Interventions

  • Continue saline lock, O2, cardiac and ST segment monitor, nitrates prn, daily aspirin, and NO CAFFIENE if persantine is planned, NPO six hours before stress test.
  • Serial Troponin I and ECGs at 2 and 6 hour from first ED blood draw
  • No 6-hour level needed if negative provocative test done after 2hr draw
  • 6 hour lab needed if positive “delta” (normal, but >50% rise) between 1st two labs
  • Repeat EKG based on symptoms or ST monitor alert – show to CDU physician STAT
  • Stress testing and cardiac Imaging - if initial and 2 hour and “delta” markers are negative

Discharge Criteria

Home

    • Acceptable VS, stable symptoms, no serious cause of symptoms identified
    • Normal serial cardiac markers and EKGs
    • Negative provocative test or cardiac imaging for ACS – no ischemic or reversible defects identified.

Admit

    • Unstable VS
    • Positive cardiac markers or EKGs
    • Positive provocative test – ischemic or reversible perfusion defect
    • CDU or personal physician discretion
    • Serious alternative diagnosis, e.g. PE, aortic dissection




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