Assessment
Table 2. Guidelines for the Identification of ACS Patients by
ED Registration Clerks or Triage Nurses
Registration/clerical staff
Patients with the following chief complaints require immediate assessment by the triage
nurse and should be referred for further evaluation:
• Chest pain, pressure, tightness, or heaviness; pain that radiates to neck, jaw,
shoulders, back, or one or both arms
• Indigestion or "heartburn"; nausea and/or vomiting associated with chest discomfort
• Persistent shortness of breath
• Weakness, dizziness, lightheadedness, loss of consciousness
Triage nurse
Patients with the following symptoms and signs require immediate assessment by the
triage nurse for initiation of the ACS protocol:
• Chest pain or severe epigastric pain, nontraumatic in origin, with components
typical of myocardial ischemia or MI:
▶▶ Central/substernal compression or crushing chest pain
▶▶ Pressure, tightness, heaviness, cramping, burning, aching sensation
▶▶ Unexplained indigestion, belching, epigastric pain
▶▶ Radiating pain in neck, jaw, shoulders, back, or one or both arms
• Associated dyspnea
• Associated nausea and/or vomiting
• Associated diaphoresis
If these symptoms are present, obtain stat ECG.
Medical history
The triage nurse should take a brief, targeted, initial history with an assessment of
current or past history of:
• Coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI),
CAD, angina on effort, or MI
• Nitroglycerin (NTG) use to relieve chest discomfort
• Risk factors, including smoking, hyperlipidemia, hypertension, diabetes mellitus,
family history, and cocaine or methamphetamine use
• Regular and recent medication use
The brief history must not delay entry into the ACS protocol.
Special considerations
Women may present more frequently than men with atypical chest pain and other symptoms.
Diabetic patients may have atypical presentations due to autonomic dysfunction.
Elderly patients may have atypical symptoms such as generalized weakness, stroke,
syncope, or a change in mental status.
Adapted from National Heart Attack Alert Program. Emergency Department: rapid identification
and treatment of patients with acute myocardial infarction. Bethesda, MD: US Department of
Health and Human Services. US Public Health Service. National Institutes of Health. National
Heart, Lung and Blood Institute, September 1993. NIH Publication No. 93–3278.
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