Evidence-Based Practice in Chest Pain Diagnosis - Essay Example

? Evidence Based Practice Introduction The management of chest pain and pressure is serious and requires the best practice which is evidence based. Being the most common complaint with multiple etiologies, the diagnosis and initial treatment of such complaints is very important which is usually provided by the paramedics. The main aim of the essay is to establish the most appropriate initial management strategy for complain of chest pressure in patients with a cardiac etiology. Chest pain or pressure is the most common complaint and accounts for up to 40% of the visits to the emergency department (Ruigomez, Rodriguez, Wallander, Johansson, & Jones, 2006). It is not only a common complaint but is also quite complicated to diagnose as it can be caused for a number of reasons including non-cardiac ones. It is therefore crucial for paramedics to be able to differentiate between cardiac and non-cardiac chest pain and/or pressure and provide the most appropriate initial management while they are taken to the hospital. Medical Case A team of paramedics were dispatched to an office building for a 49 year old male patient with a complaint of chest pressure. The team reaches the location within the seven minutes response time and the female co-worker informs that even though the patient had taken the heart medicine, he was still in pain. As the paramedics are escorted to the patient, he is sitting in his office chair with a fearful look. He has clenched fists against his chest and it is clear that the patient in diaphoretic. The initial assessment performed on the patient revealed that the patient is conscious and complains “I’m having a lot of pressure in my chest, and I’m sick to my stomach”. His airway is patent; breathing and radial pulse are normal while the skin is pale, cool, and diaphoretic. It was revealed through the cardiac monitor that the sinus rhythm of the patient was normal at 70 beats/min in lead II (Rahm & Pollak, 2009). A history and physical examination is performed while the stretcher is retrieved from the ambulance it is found that the onset of pain was sudden and the patient was worried because no matter what he did it wouldn’t stop. It was further found that it was a feeling of pressure in the chest and not pain while the severity was rated 7 on a scale of 10 by the patient (Rahm & Pollak, 2009). The pressure began an hour back during which time the patient had already taken three nitroglycerin sprays. No obvious trauma was found in the chest examination as the chest wall was moving symmetrically. The jugular veins were also normal. A 12-lead ECG is obtained while the patient is placed on the stretcher and the ECG examination confirms that the patient needs to be taken to the hospital immediately. An IV of normal saline is initiated in order to keep the vein open (KVO) while the baseline signs and sample history are obtained. The following information is collected for baseline (Rahm & Pollak, 2009, p. 3): Blood Pressure: 134/84 mm Hg Pulse: 74 beats/min, strong and regular Respirations: 18 breaths/min and unlabored Oxygen Saturation: 97% (on 100% oxygen) Signs and Symptoms: Chest pressure, diaphoresis, and nausea Allergies: Codeine and penicillin Medications: Atenolol (Tenormin), nitroglycerin Pertinent Past History: Hypertension and angina pectoris Last Oral Intake: Sandwich and Coffee 2 hours back Prior Events: “I was sitting at my desk working on a manuscript when it began” The patient informs that even after the intake of 3 nitroglycerin the pressure in his chest has not eased and complains of a pounding headache after the intake of nitroglycerin. The patient is then administered Morphine sulfate via slow IV push which brings down the intensity of chest pressure within five minutes as the patient reports that the pressure is now down to 3 (which were 7 earlier). Once the pain specific treatment has been administered the blood pressure is checked again which is now 118/70 mm Hg and the patient is transported to the hospital (Rahm & Pollak, 2009). Clinical Question In order to provide the most appropriate initial care for the patient and better understand the signs and symptoms of the patient’s suffering, the following answerable question was formulated: What kind of initial management id needed to ensure the well-being of the patient? Since paramedics are the first to arrive at the scene and it is up to them to either stabilize or worsen the condition of the patient, it is important to make use of best practice. In support of the first question, the secondary question formulated is of whether or not evidence based practice show that Morphine sulfate is helpful in case nitroglycerin fails to relieve the pain or pressure in chest for patients with cardiac etiology? Methodology In order to come up with the most appropriate initial management of such a complaint, a systematic review of literature in order to fully explore the topic and take different perspectives in to consideration. Data was collected using different peer reviewed journal articles, reports, and medical books, the source of which is provided in the reference list given in the end. The inclusion criteria used for articles to be used in the essay were: The material must include investigations in which patient with a cardiac etiology are taken in to consideration. The interventions recommended in the reports and articles must specifically be for patients with a cardiac etiology The timeline set for data was of past ten years but an effort was made to mainly make use of studies conducted in the past five years. The search terms used to gather data included the following: Chest pain/pressure Cardiac etiology Initial management and treatment Paramedic care Initial Management for Chest Pain and Pressure It is very important to properly diagnose acute chest pain or pressure and identify risks as the initial intervention can significantly improve the outcome. If the complaint of chest pressure or pain is diagnosed with myocardial infraction, appropriate initial care is needed but in case it is ruled out, then attention needs to be given to other cardiac and non-cardiac causes. In order to make the diagnosis, it is important to collect the history of chest pain. A myocardial infraction may be identified as the cause if the pain lasts for more than 20 minutes and nitroglycerine does not elevate the pain (Conti, 2011). It is also important to collect information regarding pain in other body parts including neck, jaw, left arm, etc. the pain is no necessarily severe, especially in the elderly who may report fatigues, dyspnea, etc. Other symptoms that may be reported include hypotension, narrow pulse pressure, bradycardia or tachycardia, and basal riles (Werf, et al., 2003). Obtaining an electrocardiogram is very important in the initial management as the result may not be normal even at an early stage (Glickman, et al., 2012). Efforts should be made to initiate reperfusion therapy has proven to be useful in case of elevation of the ST-segment (Jintapakorn, Lim, Yipintsoi, Moleerergpoom, Srimahachota, & Sriyadthasak, 2010). However, it has been found that infractions may not show up in the ST-segment elevation even when it has been proven and thus is it recommended that ECG should be obtained after short intervals and compared to the previous results (Werf, et al., 2003). ECG monitoring is crucial for the initial management of such complaints as it helps in the early identification of arrhythmias which can prove to be life threatening (Khandaker, et al., 2010). Though it is routine to gather blood sampling for serum makers it is recommended that that reperfusion treatment should not be delayed until after the results are obtained (Jintapakorn, Lim, Yipintsoi, Moleerergpoom, Srimahachota, & Sriyadthasak, 2010). As an alternative, it is suggested that elevated markers of necrosis may be used in order to decide whether or not reperfusion therapy is to be administered. A two dimensional ECG is also very useful in the diagnosis and treatment of acute chest pain (Khandaker, et al., 2010). The initial diagnosis of an acute myocardial infraction is made on basis of the following (Werf, et al., 2003): History of chest pain and discomfort ST-segment elevations (may require a number of ECG recordings) Elevated markers of myocardial necrosis 2D echocardiography and perfusion scintigraphy (to rule out the presence of an acute myocardial infraction) Once the above mentioned measures have been taken to establish an initial diagnosis, the focus of attention should be on the relief of pain, anxiety, and any other discomfort which the patient may be experiencing. Since pain is associated with the activation of the sympathetic nervous system, it can lead to vasoconstriction which further increases pressure on heart (Werf, et al., 2003). The most commonly used intravenous opioids include morphine or diamorphine (4 to 8 mg) followed by administration of 2mg pills every five minutes until the intensity of pain significantly drops. It is suggested that intramuscular injections should be avoided in such a situation (Khandaker, et al., 2010). Antiemetics may also be administered alongside in case the side effects or nausea, hypotension, and breathing problems are accompanied. In case the repeated administration of opioids is unable to relieve the pain, nitrates may be used, it is important to note that some patients may also experience shortness of breath and may require administration of oxygen (Ruigomez, Rodriguez, Wallander, Johansson, & Jones, 2006). It is recommended that blood and oxygen levels must be checked throughout the process. Tranquillizers may be also be used for patients who face sever anxiety during the process. Though opioids usually help in relieving anxiety along with chest pain and pressure, extra dose of tranquillizers may be needed for certain patients (Werf, et al., 2003). Evidence Based Practice Evidence based practice implies that the healthcare professional makes used of the best practice available to take care of the client. The external clinical evidence present provides different perspectives and options that are available and also identifies methods that have proven to be most effective in the past in the given field (Coats, 2004). This evidence combined with the personal knowledge and experience of the caretaker ensures that the patient receives quality care. EBP does not only highlight the strengths but also the weaknesses of a given practice so the person is well aware of the consequences of the actions he or she is about to take (Doust & Del-Mar, 2004). It is agreed upon by many professionals in the medical field that EBP has proven to be very effective. However, there is not enough evidence to support the claim that EBP actually works. Conclusion Based on the review of the literature presented above, it can be said that being that chest pain being the most common problem with multiple causes, it is important for paramedics to be able to differentiate between cardiac and non-cardiac chest pain and pressure. Accordingly, they should make used of evidence based practice to provide quality initial management for patients. The process includes appropriate measures to establish initial diagnosis and toe relieve pain. List of References Coats, V. (2004). Randomised controlled trials — almost the best available evidence for practice. Journal of Diabetes Medicine. Conti, C. R. (2011). Intravenous Morphine and Chest Pain. Clinical Cardiology, 34(8), 464-465. Doust, J., & Del-Mar, B. (2004). Why do doctors use treatments that do not work? British Medical Journal. Glickman, S., Shofer, F., Wu, M., Scholer, M., Ndubuizu, A., Peterson, E., et al. (2012). Development and validation of a prioritization rule for obtaining an immediate 12-lead electrocardiogram in the emergency department to identify ST-elevation myocardial infarction. American Heart Journal, 163(3), 372-382. Jintapakorn, W., Lim, A., Yipintsoi, T., Moleerergpoom, W., Srimahachota, S., & Sriyadthasak, O. (2010). Consequence and factors related to not offering reperfusion therapy in STEMI. Angiology, 60(6), 689-697. Khandaker, M. H., Espinosa, R. E., Nishimura, R. A., Sinak, L. J., Hayes, S. N., Melduni, R. M., et al. (2010). Pericardial Disease: Diagnosis and Management. Mayo Clin Proc, 85(6), 572-593. Rahm, S. J., & Pollak, A. N. (2009). Medical Case Studies for the Paramedic. Jones & Bartlett Publishers. Ruigomez, A., Rodriguez, L., Wallander, M., Johansson, S., & Jones, R. (2006). Chest pain in general practice: incidence, comorbidity and mortality. Fam Pract, 23(2), 167-174. Werf, F. V., Ardissino, D., Betriu, A., Cokkinos, D. V., Falk, E., Fox, K. A., et al. (2003). Management of acute myocardial infarction in patients presenting with ST-segment elevation. European Heart Journal, 24(1), 28-66. Read More