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Should you do an EKG? Err on side of caution!
Get life-saving data in minutes
ED nurses at St. Elizabeth Healthcare Florence (KY) have cared for several healthy patients under age 35 with no history or family history of heart disease, who were having a cardiac event, reports Ben Brooks, RN, BSN.
"We had a 19-year-old healthy woman come into the ED complaining of chest pressure, with vague symptoms," he says. The triage nurse ordered an EKG to be completed, which showed an acute myocardial infarction (MI), and the patient was later sent to the cardiac catheterization lab. "Her MI was the result of a tumor on her heart that was found during the cath," says Brooks
Emergency nurses "must be very liberal" with obtaining EKGs, advises Jeffery Chambers, RN, an ED nurse at Massachusetts General Hospital in Boston and member of the hospital's STEMI committee. "An EKG is an easy, non-invasive tool that provides life-saving data within minutes."
James Noland, CRNP, BC-PNP, MSN, CEN, CCRN, an ED nurse practitioner at Huntsville (AL) Hospital, says that many patients complaining of chest pain have an "initially benign appearance. Early recognition with prompt intervention is key to survival."
At Huntsville's ED, patients 30 or older with a chief complaint of chest pain or discomfort, chest pressure or tightness, "heartburn" or epigastric pain, complaints of heart racing or heart too slow, a syncopal event, onset of stroke symptoms in the past 24 hours, difficulty breathing with no obvious non-cardiac cause, and patients older than 45 with severe weakness should get a 12-lead EKG within five minutes.
Heart Alert called
Huntsville's ED nurses make sure that a complete blood count, electrolyte profile, and the first set of cardiac enzymes are drawn and sent to the lab. "The second set is drawn two hours after the first," says Noland. "If the patient is taking aspirin at home, the time of the last dose is documented."
If indicated, nitroglycerine paste is applied and the patient is given an appropriate dose of morphine. If it is determined that the patient is having an acute MI, or acute ST-segment elevation is noted, the ED physician directs the staff to call a Heart Alert.
"A designated number is called, and the operator is told that a Heart Alert needs to called," says Noland. The paging operator is given the patient's room number, and members of the Heart Alert team are notified via pager.
The ED nurse immediately begins preparing the patient for the cardiac catheterization lab by obtaining two intravenous lines, administering medications, initiating and completing the documentation, and giving the report to the cardiac catheterization lab personnel.
"While in the ED, the patient receives fibrinolysis medications if needed," says Noland. "The interventional cardiologist performs angioplasty and stent placement as indicated." (See related stories on a pre-triage EKG protocol and pain assessment below.)
For more information on obtaining EKGs in the ED, contact:
Identify MIs with pre-triage EKG protocol
Pre-triage protocol, says Judy Drummer, RN, CEN, MA, director of nursing at the ED at State University of New York Downstate Medical Center in Brooklyn, was established for EKGs. These steps are taken:
1. An EKG associate greets all incoming patients at ambulatory triage, obtains vital signs, and identifies the patient's chief complaint.
2. If the patient complains of chest pain, the EKG associate obtains an EKG and gives it to a physician for reading.
3. If the EKG does not show any indication of a cardiac event, the patient is triaged and taken to the appropriate location.
"The exception is when the triage nurse, after asking all the 'right' questions, suspects the pain might be cardiac in origin," says Drummer. Drummer says to ask these questions:
4. If the EKG shows a suspicious cardiac abnormality, the patient goes straight to the acute treatment area for treatment, and is triaged while the physician examines the patient.
Suspect MI? Then ask patient to point to pain
A 72-year-old woman complained of stomach pain, and told ED nurses that the pain got worse even after she took antacid medication, recalls Judy Drummer, RN, CEN, MA, director of nursing at the ED at State University of New York Downstate Medical Center in Brooklyn.
The patient had no cardiac history, but when the triage nurse asked her to point where the pain was coming from, she pointed to her chest, not her stomach, says Drummer. "A stat EKG was done, which showed ST elevation in leads II and III," says Drummer. "The lab result showed an elevated troponin level, and the patient was admitted to the [critical care unit]."