Episode 2 – An inevitable call for a junior doctor on-call. Whether it’s a STEMI or a panic attack, a solid foundation will set the patient up for the best outcome.
1st step (pending severity) – History
- Observe patient during history (Is there; localized pain, pain on inspiration/expiration, tachypnoea, Levine’s sign)
- Is there a history of ACS (+ the patient’s risk factors for the same)
- SOCRATES (especially character, severity, and time onset)
2nd step – Your ABC’s
ABC MOVE – a fantastic tool that you should approach any ’emergency’ with.
- Monitoring (SpO2 monitoring, SIBP, etc)
- Oxygen (nasal prongs to start)
- Venous access
Even if this is all you do – you save the Medical Reg or other senior help a lot of work and provide them with a strong platform for further treatment.
Step 3 – Examination
- GCS (a rough estimate) – can they talk to you or not
- Chest – is there clinical correlation with the ECG
- Chest – Lungs (multiple pathologies can be picked up with your steth!)
- Legs (?DVT, what is their Well’s score?)
Step 4 – Investigations
- Renal/Liver/Bone profile
- D-dimer (if indicated)
- Chest X-Ray (a CTPA can also be ordered at this time)
- ECG (if not done already) – NB: ALWAYS compare with a previous one
Breath! We have done a lot so far, but all very straight forward. If the chest pain is severe enough and/or the ECG has shown ischemic changes the Med Reg (or the Arrest team) is on the way, all investigations have been sent or processed.
Next question – what could it be?
- Aortic dissection
- Costochondritis (Tietze’s syndrome)
So let’s say it is an NSTEMI – 10 mins of you being the only doctor
- ABC MOVE*
- Oxygen – Non-rebreather 15L O2
- Call for senior help
- Investigations above
- MONA is good from here
Chest pain is a broad term as you can see with the differentials above. If it is as severe as a STEMI you won’t be alone for long, but for the less acute the above foundation should serve as a definitive starting point to treating it.