Chest Pain & Suspected STEMI Protocol: Step-by-Step for Student Nurses
When a patient suddenly clutches their chest, breaks into a cold sweat, and reports heavy, crushing pain — every second counts. Here is your ward-ready protocol.
1. Clinical Assessment: Is This Cardiac Chest Pain?
When a patient reports chest discomfort, quickly assess the pain while alerting the team. Use the **SOCRATES** framework alongside these classic features:
🫀 Classic Features of Ischaemic Cardiac Pain
- Nature: Heavy, crushing, tight band, or burning — often described as “an elephant sitting on my chest.”
- Radiation: Spreads to left arm, shoulder, neck, jaw, or upper abdomen.
- Assymptoms: Profuse cold sweat, nausea, breathlessness, feeling of impending doom.
- ⚠️ Atypical Presentation: Elderly, women, and those with diabetes may have no central chest pain — watch for sudden breathlessness, confusion, fatigue, or unexplained collapse.
2. The 10‑Minute Rule: ECG Recognition
National guidance: a 12‑lead ECG must be recorded and reviewed within 10 minutes of presentation.
⚡ ECG Patterns — What You’re Looking For
ST‑segment elevation ≥1 mm in two contiguous limb leads or ≥2 mm in V2–V3; or new Left Bundle Branch Block. Means complete artery occlusion.
🚨 Action: Activate Primary PCI pathway / crash call immediately!
ST depression, T‑wave inversion — or a normal‑looking ECG. Partial occlusion confirmed via rising Troponin levels.
⚠️ Action: Urgent review, continuous monitoring, serial bloods.
3. Initial Emergency Management: MONAC Protocol
While help is on the way, deliver this evidence‑based bundle:
💊 THE MONAC ACS INTERVENTION BUNDLE
2.5–5 mg IV with antiemetic (e.g., Metoclopramide 10 mg). Eases pain and reduces heart muscle oxygen demand.
Target SpO₂ 94–98% (88–92% if known COPD). Do not give high‑flow oxygen to non‑hypoxic patients — it narrows coronary arteries.
1–2 sprays repeat every 5 min (max 3 doses). Check BP first — hold if systolic < 90 mmHg.
Give immediately — ask patient to chew it for faster absorption.
Ticagrelor 180 mg or Clopidogrel 300–600 mg loading — prescribed by medical team before transfer.
4. Escalation Script — Word‑for‑Word SBAR
Speak clearly and confidently when bleeping the registrar or cardiac team:
🗣️ SBAR Handover — Chest Pain / STEMI
- S — Situation: “This is Student Nurse [Name] on [Ward]. I’m calling about [Patient Name] who has severe crushing chest pain and a diagnostic ECG.”
- B — Background: “[Age], admitted [date]. Relevant history: [hypertension / diabetes / previous MI / smoking]. Current diagnosis: [e.g. post‑op recovery].”
- A — Assessment: “Pain 9/10 radiating to jaw. HR 110, BP 150/90, SpO₂ 96%. Diaphoretic and nauseous. ECG shows ST elevation V2–V4. Aspirin given, GTN x1 given.”
- R — Recommendation: “Please attend urgently to review the ECG and activate the Primary PCI pathway.”
5. While Awaiting Review / Transfer
- Cardiac monitor attached — watch for dangerous ventricular rhythms.
- Crash trolley / defibrillator to bedside — be ready for arrest.
- Secure IV access — two large‑bore cannulas; take bloods (Troponin, FBC, U&Es, clotting, Group & Save).
- Nil by mouth — in case urgent angiography or surgery is needed.
- Reassure the patient — keep them calm, upright, and resting. Anxiety raises oxygen demand.
Looking for another emergency protocol?
Head back to the main directory to access rapid guides for STEMI, Sepsis, Hypoglycaemia, Anaphylaxis, and more.
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