Page 53 - Critical Care Notes

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Clinical Presentation
Chest pain manifests as follows: substernal pain, tightness, dullness, fullness,
heaviness, or pressure; dyspnea; syncope; and pain radiating to arms, epigas-
trium, shoulder, neck, or jaw. Women may experience more atypical symptoms
such as back pain and GI symptoms (e.g., indigestion, nausea and vomiting,
and abdominal fullness), whereas men may experience typical symptoms such
as midsternal chest pain radiating to the left arm.
Diagnostic Tests
■ 12-lead ECG
■ Lab work: cardiac markers: creatine kinase (CK), creatine kinase–myocardial
band (CK-MB), troponin I (TnI), and myoglobin
■ Exercise or pharmacological stress test
■ Echocardiogram
■ Nuclear scan: single-photon emission computed tomography (SPECT), MRI
with gadolinium enhancement (MUGA)
■ Cardiac catheterization and coronary artery angiography
■ Percutaneous coronary intervention (PCI)
■ Chest x-ray
■ MRI/MRA
■ Hgb, CMP, lipid panel, BNP
Management
■ Calculate TIMI Risk Score for patients with unstable angina (UA) and non–
ST-elevation Ml (NSTEMI). Estimates mortality for patients with unstable angina
and NSTEMI. Refer to: http://www.mdcalc.com/timi-risk-score-for-uanstemi/
■ Ensure bedrest.
■ Obtain ECG and lab work.
■ Assess chest pain for frequency, duration, cause that triggered pain, radia-
tion of pain, and intensity based on pain scale from 0 to 10, with 0 being no
pain and 10 being worst pain.
■ Supply O 2 .
■ Provide continuous cardiac monitoring.
■ Pharmacological treatment:
■ Early conservative, for low-risk patient: anti-ischemic, antiplatelet, and
antithrombotic drug therapy; stress and treadmill tests.
■ Early invasive: same drug therapy as early conservative but followed by
diagnostic catheterization and revascularization.
■ Administer nitroglycerin (NTG): 0.4 mg (SL or spray) every 5 min for a
total of three doses → IV infusion start at 5–10 mcg/min, titrate for pain
CV