You are in the middle of running the labs for all of your patients when you get a page. It says: Mr. Roberts is complaining of chest pain.—Pat MacDonald RN, phone 5-1234.
You remember that Mr. Roberts is on the exact other side of the hospital from where you are now. You pull out your cell phone and return the page as you are walking to the elevator. While you are on hold, you look at your list and see that Mr. Roberts is a vasculopath who is postoperative day 2 from a right below-the-knee amputation.
You get the nurse on the phone as you push the button for the elevator.
1. What is your first question to the nurse?
2. What diagnostic tests should you order over the phone?
With disconcerting frequency you are going to be called to the emergency department, the recovery room (PACU), or the floor to see a patient who claims to have new-onset “chest pain.” Frequently this will be “nothing.” Sometimes it will be “something” and, occasionally, it will be “a really big deal.”
“What are the vital signs?”
This question determines your next response. Based on those vital signs you should initiate any needed supportive measures. Standard supportive measures include giving oxygen and pain control (both of which are protective if the patient is having an MI). If the patient is hypotensive, you should tell the nurse to call a code.
As you are going to see the patient, you can get a couple of things going so they will be available as soon as possible. An EKG is mandatory. Unless you are confident that the cause of the chest pain can be explained by some other benign process, you should also order a CXR.
In evaluating patients with chest pain, it is useful to relate the likely epidemiological frequency of the problem to (most importantly) How Big A Deal If You Miss It (HBADIYMI) (see Table 22-1). Note that there are 6 diagnoses with HBADIYMIs of 3+ or higher.
Table 22-1. Causes of Chest Pain |Favorite Table|Download (.pdf)
Table 22-1. Causes of Chest Pain
|Patient Presentation||Likelihood||HBADIYMI||First Screening Test|
|Acute myocardial infarction||+++||+++||12-Lead EKG|
|Pulmonary embolism||++||+++||Spiral CT|
|Leaking triple A||+||++++||Abdominal U/S|
|Acute cholecystitis||+||+||GB ultrasound|
|Tension pneumothorax||+||++++||Vital signs (not CXR!)|
|Cardiac tamponade||+||++++||Vital signs|
Acute myocardial infarction...