MONA LISA for acute chest pain.


Morphine

Oxygen

Nitro-Glycerin

Aspirin

 

Listen to heart sounds

Intensive Care

Stat Labs

Analyze the ECG.

When your patient presents with or complains of sudden onset chest pain use this friendly pneumonic for quick assessment and intervention. Interventions are not in order.

As with all orders and interventions, these must be done in the context of facility protocol or physician order.  The goal of these interventions is to determine the cause of the chest discomfort and promptly initiate appropriate therapy.

The time for initial assessment, including ECG, and preliminary management of a patient with possible acute coronary ischemia is ideally 10 minutes from presentation

Morphine

Intravenous morphine sulfate at an initial dose of 2 to 4 mg, with increments of 2 to 8 mg, repeated at 5 to 15 minute intervals, should be given for the relief of chest pain and anxiety. Morphine can reduce sympathetic stimulation caused by pain and anxiety, thereby decreasing cardiac workload and risks associated with excess catecholamines.

Oxygen

Supplemental oxygen should be initiated to maintain oxygen saturation above 90 percent.

Nitro-Glycerin

In most cases, sublingual nitroglycerin should be administered at a dose of 0.4 mg every five minutes for a total of three doses, after which an assessment of blood pressure and pain relief should guide the need for intravenous nitroglycerin.  Do not administer nitrates if the patient has had sildenafil (Viagra), vardenafil (Levitra), or tadalafil (Cialis). The combination can lead to severe hypotension. Pain relief with nitroglycerin in an acute care setting is not helpful in distinguishing cardiac from noncardiac chest pain. Nitro is predominantly for pain relief.

Aspirin

Aspirin 162 to 325 mg given.  Aspirin produces an inhibitory effect on platelet aggregation, hopefully preventing the offending clot from growing.

Listen to heart sounds

Various abnormalities can be found on auscultation, such as a third and fourth heart sound, systolic murmurs, paradoxical splitting of the second heart sound, a pericardial friction rub and rales over the lung.

Intensive Care

Call bed control, you might need a bed.

Stat Labs

CARDIAC BIOMARKERS — Serial serum biomarkers (sometimes referred to as cardiac enzymes) of acute myocardial damage, such as troponin T and I, are essential for confirming the diagnosis of infarction. Cardiac biomarkers are substances that are released into the blood when the heart is damaged or stressed. Labs are drawn serially from onset of chest pain, Q 90 Min x3. Levels will rise as the damaged heart releases more biomarkers.

Analyze the ECG.

From UptoDate:

 When present, ECG abnormalities are an early sign of myocardial ischemia. Criteria for the two major categories of electrocardiographic manifestations of acute myocardial ischemia are listed here:

  • Findings consistent with ST elevation myocardial infarction (STEMI): New ST elevation at the J point in two anatomically contiguous leads using the following diagnostic thresholds: ≥0.1 mV (1 mm) in all leads other than V2-V3, where the following diagnostic thresholds apply: ≥0.2 mV (2 mm) in men 40 years; ≥0.25 mV (2.5 mm) in men <40 years, or ≥0.15 mV (1.5 mm) in women.
  • Findings consistent with Non ST elevation myocardial infarction or unstable angina: New horizontal or down-sloping ST depression ≥0.05 mV (0.5 mm) in two anatomically contiguous leads and/or T inversion ≥0.1 mV (1 mm) in two anatomically contiguous leads with prominent R wave or R/S ratio >1.
More on ECG assessment and terminology in the future with Dr. Nick. Simply put, STEMI means the coronary artery(ies) are completely occluded and need to be reopened STAT in the cath lab. N-STEMI MI’s are partial occlusions that can be managed a little more conservatively.

 

Source:
Initial evaluation and management of suspected acute coronary syndrome in the emergency department. Ryan, Reeder et all. 2012. UptoDate.com

 

Disclaimer:
This is not an exhaustive protocol for the management of chest pain. Use only under MD guidance and facility approval at your own risk.

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