3-12
Galloping heart sounds (like hoof beats) suggest cardiac or pulmonary embolism. Velcro rubbing sounds with
each heartbeat suggests pericarditis.
Abdomen: Right upper quadrant tenderness suggests gall bladder. Peritoneal findings suggest ruptured
peptic ulcer or pancreatitis
Extremities: Pulse deficit suggests aortic dissection. Swelling and tenderness of the calf or thigh suggests
a source for pulmonary embolism.
Using Advanced Tools:
WBC for infection (pneumonia). EKG: ST elevation (1mm or more) is supportive of an acute myocardial
infarction. ST depression of 1mm suggests ischemia. ST elevation, along with PR depression suggests
pericarditis that can lead to tamponade.
Plan:
Primary Treatment – Basic
Rest to decrease oxygen consumption. Oxygen to bring the oxygen saturation above 95%
Sips of water only, until stable
Aspirin 325 mg chewed (A single aspirin reduces the risk of angina going on to myocardial infarction or
death by 50%.)
Intravenous line for IV drug access and Normal Saline Solution at 100cc/hr (or bolus 1000cc to bring the
systolic BP over 100)
Insert 16 gauge, 6 inch IV needle over the 2nd rib on the side of the chest with decreased breath sounds
if tension pneumothorax is suspected
Endotracheal intubation if in shock with oxygen saturation under 80%
Morphine sulfate 2mg IV repeated q 5 minutes until relief of pain or sedation
Use Narcan if over-sedation occurs
Repeat vital sign determinations (q 15 minutes) until stable
Primary Treatment – Advanced
Suspect Coronary Cause: ASA 325 mg po daily. Low molecular weight heparin 1mg/kg SC q 12 hrs.
Propranolol 40-80 mg po qid (to keep HR < 80) (also treats MVP). Verapamil 80 mg po qid if history of
asthma precludes use of propranolol. Nitroglycerin 0.4mg SL q 5 minutes X 3 doses or pain relief
Diazepam 5mg po qid for 48 hours for sedation. Furosemide 40mg po if rales present. Atropine 1mg IV
(repeat X1 in 5 minutes) if HR <50. Lidocaine 100mg IM if pulse is irregular (or PVCs present)
Suspect Pulmonary Embolism: Heparin 10,000 units IV followed by 12,500 units SC q 12 hrs. Treatment of
pulmonary embolism is directed solely at the prevention of further emboli. (see Respiratory: PE)
Suspect Aortic Dissection: Propranolol 40-80 mg po qid. Diazepam 5mg po qid. NO HEPARIN!
Suspect Pneumothorax: Oxygen to >95% saturation; consider needle decompression (see Procedures:
Thoracostomy, Needle)
Suspect GI Cause (reflux, dyspepsia): Liquid antacid, 1 tablespoon q 2-4 hrs. Cimetidine 400mg po tid or
famotidine 20mg po bid.
Suspect Rupture of the Esophagus or Stomach: NPO and refer to GI Chapter for treatment
Suspect Pericarditis: ASA 650 mg po q 4 hrs or ibuprofen 800 mg tid. If pain not relieved in 12 hours,
prednisone 60mg po qd
Suspect Tamponade: If BP is falling, perform pericardiocentesis (see Procedures)
Suspect Shingles: Codeine 60mg po q 4-6 hrs (see Dermatology: Herpes Zoster)
Patient Education
General: Healthy lifestyle.
Activity: Do not restrict physical exertion if medical condition not life threatening.
Diet: High fiber, low cholesterol, low fat
Medications: Take exactly as prescribed. Beta-blockers cause tiredness and slow HR
Prevention: Discontinue smoking; obtain treatment for hypertension and hyperlipidemia
Follow-up Actions
Wound Care: Keep puncture sites clean