On initial assessment by medical staff, clinical history and symptoms are obtained and differential diagnosis excluded (see additional information for differential diagnosis). In accordance with local protocols an initial management plan is initiated and Hamish is referred for chest pain assessment.
Hamish is referred for chest pain assessment.
| Stat Doses and Pre-medication Drugs | |||||
|---|---|---|---|---|---|
| Date | Drug | Dose | Route | Time | Prescriber |
| 16/6/13 | GTN SPRAY | 2 puffs | S/L | 1335 | – |
| 16/6/13 | MORPHINE | 2.5mg | IV | 1340 | – |
| 16/6/13 | METOCLOPRAMIDE | 10mg | IV | 1340 | – |
| – | – | ||||
| 16/6/13 | CLOPIDOGREL | 300mg | ORAL | 1345 | – |
| 16/6/13 | FONDAPARINUX | 2.5mg | SUBCUT | 1345 | – |
| – | – | – | – | – | – |
- GTN Spray
1-2 puffs of a GTN spray taken sublingually is usually the first choice treatment of cardiac chest pain. In addition to any stat doses, it should be prescribed for use as required. - Morphine
Used if GTN fails to control chest pain. Dose will depend on factors such as age and frailty, but is usually between 2.5 and 10mg. Should be given intravenously (not intramuscularly or subcutaneously) due to the possibility of poor tissue blood supply. May help with anxiety as well as pain. - Metoclopramide
Should be given with morphine to minimise nausea and vomiting associated with both morphine and cardiac chest pain. Usual dose is 10mg which can be given up to three times a day. - Aspirin
All patients should receive a loading dose of aspirin 300mg unless they are known to be truly allergic. Hamish did not get this because it had been given by his GP. It may also have been given by paramedics if he was attended by the ambulance service. Usual maintenance dose after this is 75mg once daily. - Clopidogrel
Patients who are 75 years old or younger should receive a loading dose of clopidogrel 300mg . If they are older, then no loading dose is given (however, local guidelines may vary). Alternatives to Clopidogrel are:
Ticagrelor: 180mg loading dose.
Prasugrel: 60mg loading dose. - Fondaparinux
All patients should be treated with an injectable antithrombotic such as fondaparinux. The dose is 2.5mg once daily but is contra-indicated in severe renal impairment. An alternative is a low molecular weight heparin such as enoxaparin.
Pulse Point
Initial medication may already have been administered by paramedics or in A&E. It is important that ongoing medication is prescribed regularly (e.g. antithrombotics) or as required (symptom control). These can be reviewed once a definitive diagnosis is made.
Other medicines that the patient was taking before admission should be reviewed and a decision on whether to continue these should be made (medicines reconciliation).
