Learning Objectives

• ABCDE assessment in critically unwell patient
• ECGs interpretation
• Recognising ACS
• TIMI score / GRACE score
• ACS management
• ALS algorithms
• Case escalation

Background

• Patient self-presenting with chest pain

• Acute Coronary Syndrome

• Cardiac arrhythmia

• Patient is moved from triage to Resus for ACS management

• After ACS management, patient complains from worsening chest pain and remains conscious with BP 97/58 and palpable pulses

• ECG will show arrhythmia

• Initial assessment in triage

• Escalation and transfer to Resus

• Interpretation of investigations: ECGs / bloods

• ALS algorithms

Case

Patient self-presents to ED

41-year-old male: Adam

At triage

PC: Chest pain

HPC: Sudden onset of central non-pleuritic chest pain.

Started 2 hours ago while at work.

Radiates to left arm and associated with some SOB.

No palpitations / no N&V.

No history of previous chest pains.

PMH: Hypertension

DH: NKDA

Amlodipine

FH: Father died of MI – age 46 years

SH: Builder / smoker – 1 pack/day for 23 years / Occasional Cannabis / lives with wife

Observation & Examination

Adam looks pale and anxious.

GCS 15 (E4V5M6) T 37.2°C CRT  < 2 secs

BP 165/84 HR 52 RR 16

SpO2  95% on RA

HS I + II + nil

Chest clear with bilateral air entry

Abdomen soft / non tender