The topic I have chosen for my vignette is a patient with chest pain. The Resuscitation Council (UK 2006) recommends that clinical staff should follow the ABCDE approach when assessing and treating critically ill patients. This will help to identify the deterioration of critically ill patients.With this in mind, it is important that patients presenting with cardiovascular conditions are promptly assessed and treated. Here I am following an ABCDE assessment on a patient with chest pain. The 58-year-old (anonymous) male patient admitted with chest pain, 8hours after the onset of the symptoms. Initially patient was thinking it is heartburn and been taken gaviscon and paracetamol.
As I went to see the patient, I introduced myself and checked identity by asking the name.Patient is able to communicate.This incates that the airway is patent. Patient is looking pale and in short of breath. Complaining of heaviness and crushing pain around the chest radiating to left arm. Sat patient upright position and checked breathing. Respiratory rate is 20bpm. (9-14bpm is normal resp rate-bts guidelines). The pattern of the breathing is normal, the movement of the chest wall is equal, and symmetrical.SaO2 checked is, 95% on room air. (Above 94%is normal or 88%-92% for those with resp problem (copd) BTS 2008).I administered 35% oxygen via venturi mask. Supplemental oxygen therapy is important to maintain adequate oxygen levels in the tissues and organs when patients experiencing pain and shortness of breath. (Critical care assessment booklet)
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Patient's peripheries are cold and clammy.this indicates poorly perfused tissues. Pressed on patients finger for 5 seconds to check the capillary refill time.(in health,initial blanching should disappear within 2seconds of releasing pressure(Athern and Philpot 2002).CRT is 4 seconds. delayed CRT indicates poor perfusion(Lima and Bakker 2005). checked radial pulse is tachycardic 114bpm.rate is regular. A manual pulse should always checked, as machines that measure heart rate tend to give an averaged value and therefore do not pickup irregularities or arterial insufficiency (Torrance and Elley, 1997).HR is above systolic blood pressure indicating that patient having cardiac problem. Blood pressure is 101/54 mmhg, Temp 36 deg. Patient was very restless due to pain. Obtained ECG and showing small elevation in the ST segment in standard leads.ST elevation is the first sign of infarction. This happens when myocardium injured. ECG is showing Acute Myocardial infarction.
Pain relief is the first priority, as uncontrolled pain increases sympathetic stimulation, which leads to increased myocardial oxygen consumption. This can further aggravate the ischemia (T Moore & P Woodrow). Informed doctor about patient's condition. Inserted cannula and taken bloods for troponin t and routine investigation fbc, u&e's, coagulation profile. Doctor arrived and examined the patient, advised to give GTN spray and Diamorphine injection (GTN generates nitric oxide that is Vasoprotective.Nitrovasodilators act primarily to dilate veins and therefore has a major effect on reducing the filling pressures of the heart. This helps to reduce myocardial contraction, wall stress, oxygen demands .It is short acting, and its effects last up to 30 minutes. The sublingual route is preferred as this avoids metabolism by the liver which reduces the drug concentration (H Chummun,KGopaul,A. Lutchman 2009) Diamorphine injection 5mg intravenously given .This is both potent analgesic and has positive hemodynamic effects particularly,vasodialatation which reduces the myocardial oxygen demand. Metochlorpromide 10mg intravenously (Antiemetic) given along with opiates to minimize nausea, a side effect of opiates therapy. Aspirin and Clopidogrel 300mg given .These are antiplatelet drugs ,decrease the platelet aggregation and inhibit thrombus formation in the arterial circulation ,because in faster-flowing vessels,throbi are composed mainly of platelets with little fibrin. (BNF 2010)
Patient is not thrombolysed with streptokinase injection, because the late presentation and later administration is less effective outcome. Currently most protocols advocate a time window of 6hrs from the onset of pain during which it is appropriate to give thrombolytics.After this time it is usually considered that the risk of the drug outweigh the limited benefit gained(MrBasset's and Mr Makin's). Reassessed vital signs and pain. The pain is easing off slightly, scoring 2.respiratory rate 16bpm , HR 98bpm BP 112/68,CRT 2. Patient's condition is improving. Pain assessment is a priority because continued pain is a symptom of ongoing MI, which places additional risk on myocardial tissue (Urden et al, 2002). Repeat Diamorphine injection given as advised by doctor. Closely observed the patient, monitored breathing and oxygen saturation. Oxygen therapy continued, because it is important to assist the myocardial tissue to continue its pumping activity and to repair the damaged tissue around the site of the infarct (Sole et al, 2001).No shortness of breath at present. Repeat ECG taken in 15 minutes interval for assessment of dysrhythmias and it is noninvasive, well tolerated by patients and provides continuous information about the heart (Docherty and Douglas, 2003). Patient's blood sugar checked and it is 6.7mmol.patient has no diabetic history.
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Patient is very anxious and worried. Anxiety can play a role in acute MI. It may affect the development of further heart disease, further morbidity or prognosis, health care use and rehabilitation. (Crow et al,1996, Januzzi et al 2000).I reassured patient. Anxiety management is assigned a high priority in the early management of Acute MI. Doctor discussed with family about present condition and treatment. Family member who are anxious or upset about the patient's condition may heighten patient anxiety, research suggest that family members should provide with information to meet their needs to reduce family anxiety (Quinn et al 1996).Doctor explained to the family about patient's diagnosis and treatment. Heart rate monitored continuously by attaching telemetry. This helps to identify cardiac arrhythmias. Vitals signs and pain score recorded regularly.
Recognizing the signs of clinical deterioration and taking appropriate timely action can be a vital part of providing optimal patient care. The clinical signs of critical illness usually reflect compromised respiratory, cardiovascular and neurological function.The underlying aim of the initial interventions should be seen as a 'holding measure' to keep the patient alive,and produces some clinical improvement ,in order that definitive treatment may be initiated(Nolan et al,2005).