How to respond rapidly when chest pain strikes

Fowler, John P. Nursing; Philadelphia Vol. 26, Iss. 4, (Apr

1996): 42

Abstract

The presence of severe chest pain indicates that the clinical picture of a patient may
be deteriorating--fast. Treatment options nurses should implement when encountering
sudden chest pain in a patient are discussed.

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NONE OF THE ALARMS HAD SOUNDED in the step-down unit--not even the
alarm for Hal Dalton. His monitor showed that he remained in a steady sinus rhythm.
The only change from his admission for angina the previous day was a slightly
elevated heart rate--up to90 from 78.

So you're surprised when his call light flashes. When you respond, one glance at Mr.
Dalton's face tells you he's in severe pain--and scared.

Since his admission, Mr. Dalton's electrocardiograms (ECGs) and cardiac enzymes
have been normal, despite a preadmission history of new-onset anginaand multiple
risk factors, including smoking, hyperlipidemia, and obesity. But the presence of
severe chest pain indicates that the clinical picture may be deteriorating--fast.

Starting treatment stat

After calling for assistance, you take Mr. Dalton's vital signs. His blood pressure (BP)
is 170/110; respiratory rate, 24; and Spo2, 95%. You initiate oxygen via nasal connula
at 3 liters/minute. Another nurse obtains a 12-lead ECG while you administer 0.4 mg
sublingual nitroglycerin per Mr. Dalton's standing medication orders.

In the meantime, you ask Mr. Dalton to rate his pain on a scale of 0 (none) to 10
(most severe). He rates it a 10. You also ask Mr. Dalton about the pain's location and
quality. He describes it as squeezing and radiating tohis neck. He also reports feeling
nauseated and sweaty.

The first nitroglycerin tablet brings his pain down to an 8. You repeat his BP (150/96)
and give him a second sublingual nitroglycerin tablet. Five minutes later, per the
physician's order, you also administer 2 mg of morphine, intravenous (I.V.) push over
2 minutes.

After 20 minutes of treatment and an additional morphine dose, Mr. Dalton is

pain-free and his BP is 130/80. The on-call resident reads his 12-lead ECG and
confirms ischemic changes from the previous ECG, including T-wave inversions in
leads II, III, and aVF, and ST-segment depression in leads, I, V5, and V6. He
diagnoses unstable angina. You draw stat cardiac enzymes, to be repeated 8 and 16
hours later for comparison.

Because Mr. Dalton's chest pain recurs a short time later, the physician orders a
nitroglycerin drip that can be titrated to a maximum of 100 mcg/minute while
maintaining a systolic BP of 100 mm Hg. (See Chest-Pain Drugs at a Glance.) He also
orders aspirin, 324 mg P.O., and herapin, 5,000 units I.V. push, followed by a heparin
drip at 1,000 units/hour, with an activated partial thromboplastin time to be drawn 5
hours later. While you give Mr. Dalton aspirin, your colleague arranges for his
transfer to the coronary care unit (CCU).

Classifying angina

Mr. Dalton has unstable angina, which can occur at rest. Angina can be divided into
three types.

* Exertional angina. This common angina is defined as chest pain precipitated by the
temporary interruption of the blood (an oxygen) supply to the coronary arteries. It's
often associated with exertion or cold, which causes an imbalance between
myocardial oxygen supply and demand. Contributing risk factors include smoking,
hypertension, hyperlipidemia, obesity, diabetes, heredity, stress, and a sedentary
lifestyle. These factors can contribute to the narrowing of coronary arteries, resulting
in angina.

* Unstable angina. The cause of Mr. Dalton's chest pain, unstable (or
crescendo) angina is chest pain that occurs at rest or that has increased in frequency,
duration, or intensity. These patients require more intense medical therapy and may be
at high risk for an acute myocardial infarction (MI) or sudden death.

A patient with unstable angina may need cardiac catheterization to determine the
specific vessels involved and the amount of stenosis. Based on the results, he may
require a coronary angioplasty, arthrectomy, or other cardiac procedures to reestablish
coronary blood flow. Coronary artery bypass graft surgery may also be an option if
left main disease or triple-vessel disease is present.

* Prinzmetal's angina. Another type of resting angina, Prinzmetal's (or

variant) angina is usually the result of a lesion or coronary artery spasm. The ECG
tracing of a patient with Prinzmetal's angina may mimic an acute MI, with
ST-segment elevations. Accurate assessment and rapid treatment are required to avert
an acute MI. The preferred treatments are nitrates and calcium channel blockers,
particularly nifedipine (Procardia). Once the spasm is resolved, the ST-segment
elevations usually return to baseline.

Further treatment

Unfortunately, Mr. Dalton experienced recurrent episodes of chest pain, requiring

increasing doses of nitrates. Beta-blockers and calcium channel blockers were
added tothe regimen. He underwent cardiac catheterization the next day and had an
arthrectomy for left anterior descending and circumflex lesions. Later, while
recovering in the CCU, his I.V. medications were changed to oral formulations and he
was transferred back to your unit. He was discharged after 3 days free from recurrent
chest pain.

Your discharge teaching included instructions on medication guidelines, weight

control, stress reduction, exercise, and symptoms that should prompt Mr.
Dalton tocontact his health care provider immediately.

Because of your initial rapid response and the continuing good care he received in the
CCU, Mr. Dalton didn't have further cardiac damage and has the best chance for
recovery.

References:

Fowler, J. P. (1996). How to respond rapidly when chest pain strikes. Nursing, 26(4), 42.
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