7/23/2019 Tony Cross CDU Low Risk ACS Proforma - V3.212 Review Due June 2014
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O Erinfolami / S Dorrian
Patient Identification Label
Inclusion criteria for CDU
Cardiac sounding che
past 24 hours TIMI-RS score = 0 or Pain free on admissio Age > 18 yrs
TIMI-RS scoring (score 1 for ea
Criteria
Age > 65 yr
> 3 Coronary Artery Disease risk f
Prior stenosis > 50% (or previousST deviation on ECG> 2 angina events in < 24 hAspirin in last 7 d (regularly takenElevated cardiac markers
If unable to send patient to
--------------------------------------
Eme
LOW RISK PROB
Admitting Dr:
Patient reviewed by (M
anagement:
st pain, within
1 (see overleaf)n to CDU
Exclusion criteria:
Ongoing chest
Irrespective of• Known IHD
• Acute ECG chachanges or arrh
• Elevated cardia Suspected or p
of chest pain CCF Haemo-dynami Co-morbidity or
hospital admiss Unclear history No reliable cont
telephone
TIMI-RS SCORINGh risk)
actors (FH, Elevated cholesterol, HT, DM, Active
cute Myocardial Infarction or revascularisation)
on physicians’ advice)
TOTAL TIMI SCORE (0 OR 1 ONL
DU please document why (e.g. no spac
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Page 1
rgency Department
Tony Cross CDUBLE ACS PROFORMA
/Consultant):
ain
IMI-RS score
nges (ST/T waveythmias)
c enzymesoven alternative cause
instabilitysocial reason requiring
ion
act address and
Present?(tick)
smoker)
FOR CDU) /7
, patient too ill etc…):
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7/23/2019 Tony Cross CDU Low Risk ACS Proforma - V3.212 Review Due June 2014
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Summary of Low risk probable ACS Management Guideline
Management in ED History & examination – clinical suspicion of ACSECG baseline & further ECG after 1 hour (or prior to transfer)Aspirin 300mg po stat (if no C/I)Bloods – Lipids, FBC, U/E, Glucose, Troponin
Management in CDU
Observations &nursing care:
Full set observations,MEWS & ECG 4hrly
Medications:
Commence on statin if cholesterol > 5mmol/L: Simvastatin 20mg po nocte
Refer to cardiology or RMO if chest pain, ECG changes or elevated cTnT (at any point)
Timing of review 2n
Troponin to be taken as per hospital guidelines;
If initial sample normal, repeat in 6 hours
If initial sample raised, repeat in 3 hours AND refer to RMO
Review at 8 hours OR once 2nd
Troponin result available
Criteria foradmission(at any time or afterfinal review)
Social circumstances prevent discharge Haemodynamically unstable patient (BP >180 or <100, Pulse <50 or >100) Further episode chest pain Abnormal ECG Positive Troponin T
After final review:Criteria fordischarge +
Discharge Plan
Criteria for discharge:
No chest pain whilst in CDU
No ECG abnormalities
Negative Troponin T (at baseline and 6hrs after the last episode of pain)
Patient able to come back if they develop chest pain (If not, refer for in-patientreview). ADVICE TO RETURN IMMEDIATELY IF PAIN RETURNS
Discharge Plan:NICE IHD Risk <10% NICE IHD Risk 10 – 60% NICE IHD Risk >61%
No follow up No medication
Book patient aCoronary CT – see
below Meds - Aspirin 75mg
daily, GTN Spray,Statin if indicated
Refer to CardiologyOP
Meds - Aspirin 75mgdaily, GTN Spray,Statin if indicated
ALL PATIENTS: Appropriate patient and GP letters
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Time Flow of patients on CDU Chest Pain pathway
T r o p o n i n t i m e s
• Time initial
• Time ifabnormal
• Time ifnormal
• Estimatedtime ofpathwaycomplete
G u i d e l i n e
s o n w h e n t o t a k e T n T
• BaselineTnT
• Initial TnTnormal?repeat at6hrs
• Initial TnTraised?
Refer toMed!ardiolo"y#repeat at$hrs if stillin E%&
E ! G t i m e s
• E!G ' ( )
E%shopfloor
• E!G $ at*hrs postarri+al E%
• E!G * at ,
hrs postarri+al E%
Criteria for admission & referral to RMO/Cardiology: (EXIT PATHWAY
TO CPAU/RESUS/MAJORS AS REQUIRED):
Unstable medical condition
Further Chest pain episode
Abnormal ECG
Abnormal Troponin
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NICE definition ofangina pain
NICE defines angina as:
• Constricting pain at the front of the chest, arms, shoulders or jaw
• Precipitated by physical exertion
• Relieved by rest or GTN in about 5 minutes
All of the above = typical angina, two of the above = atypical angina, one or none ofthe above = non-anginal chest pain
NICE Riskstratification forCoronary CT Request& Disposal:
How to Assess the likelihood of CAD
EXCLUSION OFCORONARYARTERY DISEASE(CAD):
ACS is excluded following serial normal ECG’s and 2 negative Troponin, with one atleast 6 hours after chest pain episode.
EXCLUSION OF ACS DOES NOT MEAN THE PATIENT DOES NOT HAVECORONARY ARTERY DISEASE – CONTINUE ON THE PATHWAY FOR FURTHER
INVESTIGATION AND MANAGEMENT AS AN OUTPATIENT
Coronary CT**:
Inclusion criteria Exclusion criteria
10 – 60% CAD risk on NICE guideline <10% CAD risk on NICE guideline: No
follow upNormal ECG & Negative Troponin >61% CAD risk on NICE guideline: refer
to Cardiology OP (see ED Intranet)No known CAD Known CADAge: <70yrs, males >30, females >35 yr e-GFR <40BMI <38 Severe Asthma/aortic stenosis/LVF
Book CCTA via iCare, fill in cardiac CT pilot request form and follow flow chart of care