Mrs. Grace Kelly, a 69 year old recently retired bank chief executive officer is admitted via ambulance at 13.00 hours to the Emergency Department, accompanied by her husband. She experienced severe chest pain that radiated to her neck, jaw, and left arm, which started about 12.15 hours. The pain was accompanied by shortness of breath and sweating.
On arrival to the Emergency Department Mrs. Kelly is alert and tells you that she had experienced pain after returning home from her retirement dinner the previous evening. She has held senior management positions in the bank for 35 years. She described that pain as more of a burning, aching discomfort in her epigastrium, shoulders and back and thought it was indigestion and so took antacids. This pain continued all night and she felt it was a consequence of the evening’s celebration. However, when it became more intense and she became anxious and restless, her husband called the ambulance.
Report from paramedics
Patient had severe sub sternal chest pain that radiated to neck, jaw and left arm. She was pale and anxious.
Initial vital signs:
Temperature: 37.2° C
Pulse: 118 beats/minute BP: 120/70
Oxygen saturation: 93%
A 12 lead ECG was taken at her home and data transmitted to a doctor in the Emergency Department.
IV cannula was inserted into the left antecubital vein. Medications administered (MONA Acronym):
• Morphine 2.5mg IV / Maxolon 10mg IV
• Oxygen (Face Mask 6L)
• Nitrates: (glyceryl trinitrate 600micrograms sublingual) • Aspirin 100mg
Emergency Department management
Her pain was assessed using the SOCRATES acronym:
Site
Onset Character
Radiating
Associated symptoms
Time/Duration
Exacerbating Severity
The following assessments are immediately performed:
PRIMARY SURVEY
AIRWAY: No signs of obstruction or noisy breathing, talks in full sentences.
BREATHING: RR 28 breaths/min, labored; oxygen saturation: 92% (on 6L/min 02 via a Hudson mask). Bilateral basal crackles and crepitation.
CIRCULATION: HR 120 bpm BP 90/50mmHg; JVP elevated 4cm; peripheral pulses –rapid and faint; capillary refill 4 secs; extremities cool, clammy and mottled; bilateral ankle oedema; 3rd heart sound present; Temp 37.5°C.
DISABILITY: Anxious and restless, oriented in person, time, place; GCS 15/15; pain 5/10.
EXPOSURE: No bruising.
FLUIDS: I.V. inserted; no IV fluids in progress.
GLUCOSE: BGL 4.0 mmol/L
• A 12 lead ECG is performed with the following trace:
• An extra peripheral venous line and peripheral arterial line are inserted in the ED.
• She was connected to a cardiac monitor
Diagnosis
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