30 – Chest Pain in a Pregnant Patient

30 Chest Pain in a Pregnant Patient

Shahid Karim and Sarah Vause

Scenario in a Nutshell

Coronary artery dissection presenting to A+E.

Stage 1: Initial assessment of chest pain in 30-week primipara.

Stage 2: Severe chest pain with ST elevation on ECG, commence management for acute coronary syndrome (ACS).

Stage 3: Worsening acute myocardial infarction deteriorating to ventricular fibrillation (VF) arrest. Requiring advanced life support (ALS) and transferred to cardiac catheterisation lab for primary percutaneous coronary intervention (PCI).

Target Learner Groups

Appropriate members of the receiving A+E, cardiology and multidisciplinary obstetric teams.

Specific learning opportunities

Knowledge of differential diagnosis of chest pain in pregnancy

Recognition and management of acute myocardial infarction

Involve relevant specialities appropriately

Appropriate and timely management of VF arrest

Rapid decision-making and coordination to arrange transfer to cardiac catheter lab

Suggested learners (to represent their normal roles)	In the room from the start	Available when requested
A+E nurse	√
A+E ST3+	√
Cardiology ST6–7		√
Obstetric ST3+/Consultant		√
Anaesthetic CT2/ST3+		√
Other responding members of A+E team		√
Suggested facilitators
Faculty to play role of nurse in A+E performing handover on admission of patient to resus bay	√

Details for Facilitators

Patient Demographics

Name: Helen Barker

Age: 37

Gestation: 30

Booking weight: 78 kg

Parity: P0

Scenario Summary for Facilitators

37-year-old primipara. (Stopped smoking at start of pregnancy. FH father had myocardial infarction (MI) in 40s. Intermittent cocaine use outside of pregnancy.)

Attends A+E with a 3-hour history of intermittent chest pain and shortness of breath.

Initial ECG unremarkable.

Further pain of greater severity and longer duration.

ECG demonstrates ST elevation.

Given initial treatment for myocardial infarction after discussion with patient.

Constant severe pain with haemodynamic compromise and subsequent VF arrest.

Cardioverts with 1 DC shock, urgent referral and transfer for percutaneous coronary intervention.

Set-up Overview for Facilitators

Clinical setting	A+E resus bay
Patient position	Semi-recumbent on A+E trolley
Initial monitoring in place	None – just arrived in resuscitation bay
Other equipment	Nil but all equipment available
Useful manikin features	Defibrillation

Medical Equipment

For core equipment checklist see Chapter 9.

Additional equipment specific to scenario
Arterial line	Resuscitation trolley with defibrillator	Pads for defibrillation
Drugs: GTN Aspirin Clopidogrel/ticagrelor Thrombolysis LMWH	Beta blocker ACE inhibitor Statin Eplerenone

Information Given to the Learners

SBAR handover to the A+E team from the triage nurse who has brought patient straight to resus bay

Time: 14.00
Situation: Pregnant patient presenting with chest pain.
Background: 37-year-old primipara who is otherwise fit and well. 30 weeks pregnant. Intermittent chest pain for the last 3 hours with some shortness of breath.
Assessment: I was just about to perform some observations.
Recommendation: Can you please assess the patient?