Adult ECAT protocol

Chest pain

A3.2 Published: December 2023. Printed on 21 Nov 2024.

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Any person, 16 years and over, presenting with chest pain or other symptoms of acute coronary syndrome.

This protocol is intended to be used by registered and enrolled nurses within their scope of practice and as outlined in The Use of Emergency Care Assessment and Treatment Protocols (PD2024_011). Sections marked triangle or diamond indicate the need for additional prerequisite education prior to use. Check the medication table for dose adjustments and links to relevant reference texts.

Use this protocol in conjunction with NSW Pathway for Acute Coronary Syndrome (PACSA) Flowchart and PACSA Checklist.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

History prompts

Presenting complaint
Onset of symptoms
Pain assessment – PQRST
Pre-hospital treatment
Past admissions
Medical and surgical history
Current medications
Known allergies
Vaccination status, including recent COVID-19 vaccination
Identify cardiac history and/or risk factors: over 55 years, familial, hypertension, hyperlipidaemia, diabetes, smoking or Aboriginal and Torres Strait Islander

Signs and symptoms

Pain, discomfort or heaviness
Radiation of pain to jaw, shoulder, arm or epigastrium
Shortness of breath
Palpitations
Nausea or vomiting
Pallor
Diaphoresis (sweating)
Lethargy or fatigue

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Historical

Cardiac history
Cardiac risk factors

Clinical

Altered level of consciousness
Syncope
Shortness of breath
Active chest pain or other ischaemic symptoms
Ischaemic ECG changes
Arrhythmia
Hypotension
Diaphoresis (sweating)

Remember adult at risk: patient or carer concern, frailty, multiple comorbidities or unplanned return.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

Assessment	Intervention
General appearance/first impressions	Position of comfort

Airway

Assessment	Intervention
Patency of airway	Maintain airway patency Consider airway opening manoeuvres and positioning

Assessment

Intervention

Patency of airway

Maintain airway patency

Consider airway opening manoeuvres and positioning

Breathing

Assessment	Intervention
Respiratory rate and effort Auscultate chest (breath sounds) Oxygen saturation (SpO₂)	Assist ventilation, as clinically indicated Consider oxygen if dyspnoeic, titrate oxygen to maintain SpO₂ over 93% Patients at risk of hypercapnia, maintain SpO₂ at 88–92%

Assessment

Intervention

Respiratory rate and effort

Auscultate chest (breath sounds)

Oxygen saturation (SpO₂)

Assist ventilation, as clinically indicated

Consider oxygen if dyspnoeic, titrate oxygen to maintain SpO₂ over 93%

Patients at risk of hypercapnia, maintain SpO₂ at 88–92%

For possible STEMI or other high-risk ACS with haemodynamic compromise, consider nursing patient in the resuscitation area and/or attaching patient to a defibrillator.

Circulation

Assessment	Intervention
Cardiac rhythm	Attach cardiac monitor and complete 12 lead ECG within 10 minutes of clinical contact ECG must be reviewed by a senior clinician and/or ECG reading service (if available) If STEMI criteria are met, escalate as per local pathway and initiate nurse administered thrombolysis (NAT), if accredited
Perfusion (capillary refill, skin warmth and colour) Pulse Blood pressure	Assess circulation Give aspirin 300 mg, orally (chew or dissolve in water) once only, unless already given or contraindicated In patients with stable blood pressure, glyceryl trinitrate should be used as first-line therapy for pain.
Patients who: have never taken nitrates or have a SBP between 100–120 mmHg or are 65 years and over	Give glyceryl trinitrate: tablet 300 microg sublingually. Wait for 5 minutes. Check blood pressure and pain. If SBP over 100 mmHg and pain persists, repeat dose. Maximum dose 1800 microg or spray 400 microg (1 spray) sublingually. Wait for 5 minutes. Check blood pressure and pain. If SBP over 100 mmHg and pain persists, repeat dose. Maximum dose 1200 microg
All other patients: carefully titrate dose according to blood pressure and pain	Give glyceryl trinitrate: tablet 300–600 microg sublingually. Wait for 5 minutes. Check blood pressure and pain. If SBP over 100 mmHg and pain persists, repeat dose. Maximum dose 1800 microg or spray 400–800 microg (1–2 sprays) sublingually. Wait for 5 minutes. Check blood pressure and pain. If SBP over 100 mmHg and pain persists, repeat dose. Maximum dose 1200 microg
If pain persists after starting glyceryl trinitrate, give analgesia as per analgesia section
IVC and/or pathology	Insert cannula, if trained If unable to obtain IV access, consider intraosseous insertion, if trained See pathology section
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension	If signs of shock present and/or SBP less than 90 mmHg, give 250 mL of sodium chloride 0.9% IV/intraosseous bolus Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved Known or suspected congestive heart failure: monitor patient closely for signs of fluid overload

Assessment

Intervention

Cardiac rhythm

Attach cardiac monitor and complete 12 lead ECG within 10 minutes of clinical contact

ECG must be reviewed by a senior clinician and/or ECG reading service (if available)

If STEMI criteria are met, escalate as per local pathway and initiate nurse administered thrombolysis (NAT), if accredited

Perfusion (capillary refill, skin warmth and colour)

Pulse

Blood pressure

Assess circulation

Give aspirin 300 mg, orally (chew or dissolve in water) once only, unless already given or contraindicated

In patients with stable blood pressure, glyceryl trinitrate should be used as first-line therapy for pain.

Patients who:

have never taken nitrates
or have a SBP between 100–120 mmHg
or are 65 years and over

Give glyceryl trinitrate:

tablet 300 microg sublingually. Wait for 5 minutes. Check blood pressure and pain. If SBP over 100 mmHg and pain persists, repeat dose. Maximum dose 1800 microg
or spray 400 microg (1 spray) sublingually. Wait for 5 minutes. Check blood pressure and pain. If SBP over 100 mmHg and pain persists, repeat dose. Maximum dose 1200 microg

All other patients: carefully titrate dose according to blood pressure and pain

Give glyceryl trinitrate:

tablet 300–600 microg sublingually. Wait for 5 minutes. Check blood pressure and pain. If SBP over 100 mmHg and pain persists, repeat dose. Maximum dose 1800 microg

or spray 400–800 microg (1–2 sprays) sublingually. Wait for 5 minutes. Check blood pressure and pain. If SBP over 100 mmHg and pain persists, repeat dose. Maximum dose 1200 microg

If pain persists after starting glyceryl trinitrate, give analgesia as per analgesia section

IVC and/or pathology

Insert cannula, if trained

If unable to obtain IV access, consider intraosseous insertion, if trained

See pathology section

Signs of shock:

tachycardia and CRT 3 seconds and over

and/or abnormal skin perfusion

and/or hypotension

If signs of shock present and/or SBP less than 90 mmHg, give 250 mL of sodium chloride 0.9% IV/intraosseous bolus

Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved

Known or suspected congestive heart failure: monitor patient closely for signs of fluid overload

Disability

Assessment	Intervention
ACVPU	If ACVPU shows reduced level of consciousness, continue to GCS, pupillary response and limb strength
GCS, pupillary response and limb strength	Obtain baseline and repeat assessment, as clinically indicated
Pain	Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment

Exposure

Assessment	Intervention
Temperature	Measure temperature
Skin inspection, including posterior surfaces	Check and document any abnormalities

Fluids

Assessment	Intervention
Hydration status: last ate, drank, bowels opened, passed urine or vomited	Commence fluid balance chart, as required
Nausea and/or vomiting	If present, see nausea and/or vomiting section

Glucose

Assessment	Intervention
BGL	Measure BGL If BGL less than 4 mmol/L with NO decrease in level of consciousness (Yellow Zone criteria): give quick-acting carbohydrate: sugary soft drink, fruit juice or 40% glucose gel, up to 15 g, buccal reassess BGL in 15–30 minutes and repeat treatment until BGL over 4 mmol/L If BGL less than 4 mmol/L WITH a decrease in level of consciousness (Red Zone criteria) OR the patient is unable to tolerate oral intake: give 40% glucose gel, up to 15 g, buccally in incremental doses, as tolerated, while establishing IV access give 10% glucose 200 mL by IV infusion over 15 minutes, once only if delay in IV access, give glucagon 1 mg IM, once only reassess BGL in 15 minutes If the patient is unconscious or peri-arrest: give 50% glucose 50 mL by slow IV injection, once only. Use with caution as extravasation can cause necrosis if delay in IV access, give glucagon 1 mg IM, once only reassess BGL in 15 minutes Once stabilised, give patient long-acting carbohydrate and continue to check BGL hourly, or as clinically indicated

Assessment

Intervention

BGL

Measure BGL

If BGL less than 4 mmol/L with NO decrease in level of consciousness (Yellow Zone criteria):

give quick-acting carbohydrate: sugary soft drink, fruit juice or 40% glucose gel, up to 15 g, buccal
reassess BGL in 15–30 minutes and repeat treatment until BGL over 4 mmol/L

If BGL less than 4 mmol/L WITH a decrease in level of consciousness (Red Zone criteria) OR the patient is unable to tolerate oral intake:

give 40% glucose gel, up to 15 g, buccally in incremental doses, as tolerated, while establishing IV access
give 10% glucose 200 mL by IV infusion over 15 minutes, once only
if delay in IV access, give glucagon 1 mg IM, once only
reassess BGL in 15 minutes

If the patient is unconscious or peri-arrest:

give 50% glucose 50 mL by slow IV injection, once only. Use with caution as extravasation can cause necrosis
if delay in IV access, give glucagon 1 mg IM, once only
reassess BGL in 15 minutes

Once stabilised, give patient long-acting carbohydrate and continue to check BGL hourly, or as clinically indicated

Repeat and document assessment and observations to monitor responses to interventions, identify developing trends and clinical deterioration. Escalate care as required according to the local CERS protocol.

Focused assessment

Complete cardiovascular focused assessment.

Precautions and notes

The diabetic, elderly, female, or young patient may present with atypical symptoms, such as: dyspnoea, nausea, vomiting, abdominal pain, palpitations, syncope or cardiac arrest.
Serial ECGs should be compared in sequence with pre-existing ECGs.
Ensure ischaemic chest pain is relieved effectively. Pain may reflect ongoing myocardial damage.

Interventions and diagnostics

Specific treatment

If ST elevation or other ischaemic ECG changes are identified, escalate care as per local CERS protocol.

Repeat ECG every 30 minutes if symptoms continue.

Analgesia

Select pain score:

Pain score 1–3 (mild)

Give paracetamol 1000 mg orally once only

Pain score 4–6 (moderate)

Give:

oxycodone (immediate release):

16–65 years: 5 mg orally and, if required, repeat once after 30 minutes, maximum dose 10 mg
65 years and over: 2.5 mg orally and, if required, repeat once after 30 minutes, maximum dose 5 mg

and/or paracetamol 1000 mg orally once only

Pain score 7–10 (severe)

Do not give morphine or fentanyl if SBP is below 100 mmHg. Escalate as per local CERS protocol.

Give one of:

Fentanyl intranasal

16–65 years: 50 microg intranasally and, if required, repeat once after 5 minutes, maximum dose 100 microg. Dose to be divided between nostrils
65 years and over: 25 microg intranasally and, if required, repeat once after 5 minutes, maximum dose 50 microg. Dose to be divided between nostrils

Note: ensure an extra 0.1 mL is drawn up for the first dose to account for the dead space in the mucosal atomiser device

Fentanyl IV

16–65 years: 50 microg IV and, if required, repeat once after 5 minutes, maximum dose 100 microg
65 years and over: 25 microg IV and, if required, repeat once after 5 minutes, maximum dose 50 microg

Morphine IV

16–65 years: 5 mg IV and, if required, repeat once after 5 minutes, maximum dose 10 mg
65 years and over: 2.5 mg IV and, if required, repeat once after 5 minutes, maximum dose 5 mg

Morphine IM

16–65 years: 5 mg IM and, if required, repeat once after 60 minutes, maximum dose 10 mg
65 years and over: 2.5 mg IM and, if required, repeat once after 60 minutes, maximum dose 5 mg

and/or paracetamol 1000 mg orally once only

If pain does not improve with medication, escalate as per local CERS protocol.

Nausea and/or vomiting

If nausea and/or vomiting is present, give:

metoclopramide 10 mg orally or IV/IM once only (over 20 years only)
or ondansetron 4 mg orally or IV/IM. If symptoms persist after 60 minutes, repeat once, maximum dose 8 mg
or prochlorperazine 5 mg orally once only or 12.5 mg IV/IM once only

Choice of antiemetic should be determined by cause of symptoms.

Radiology

Pathology

FBC, UEC, troponin
Warfarinised: INR
For repeat troponin, refer to PACSA flowchart

Medications

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

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Drug	Dose	Route	Frequency
Aspirin ^{H, R}	300 mg	Oral (chew or dissolve in water)	Once only if not previously given
Fentanyl ^{H, R}	16–65 years: 50 microg Maximum dose 100 microg 65 years and over: 25 microg Maximum dose 50 microg	IV/intranasal	Pain score 7–10 Repeat once if required after 5 minutes to maximum dose Do not give fentanyl if SBP is below 100 mmHg
Glucagon	1 mg	IM	Once only
Glucose 10%	200 mL	IV infusion over 15 minutes	Once only
Glucose 40% gel (0.4 g/mL)	15 g	Buccal	Repeat after 15 minutes if required
Glucose 50%	50 mL	Slow IV injection	Once only
Glyceryl trinitrate	Do not give if known severe anaemia (high risk of methaemoglobinaemia) Do not give if any of the following taken (profound hypotensive effect): riociguat, currently taking avanafil, in previous 12-hour period sildenafil or vardenafil, in previous 24-hour period tadalafil, in previous 48-hour period
	For patients who have never taken nitrates, or SBP 100–120 mmHg, or 65 years and over
	300 microg Maximum dose 1800 microg	Sublingual tablet	Repeat every 5 minutes if SBP over 100 mmHg and pain persists to maximum dose
	OR
	400 microg (1 spray) Maximum dose 1200 microg	Sublingual spray
	All other patients
	300–600 microg Maximum dose 1800 microg	Sublingual tablet	Repeat every 5 minutes if SBP over 100 mmHg and pain persists to maximum dose
	OR
	400–800 microg (1–2 sprays) Maximum dose 1200 microg	Sublingual spray
Metoclopramide ^R	Over 20 years: 10 mg	Oral/IV/IM	Once only
Morphine ^{H, R}	16–65 years: 5 mg Maximum dose 10 mg 65 years and over: 2.5 mg Maximum dose 5 mg	Pain score 7–10 Do not give morphine if SBP is below 100 mmHg
		IV	Repeat once if required after 5 minutes
		IM	Repeat once if required after 60 minutes
Ondansetron	4 mg Maximum dose 8 mg	Oral/IV/IM	Repeat once if required after 60 minutes
Oxycodone immediate release ^{H, R}	16–65 years: 5 mg Maximum dose 10 mg 65 years and over: 2.5 mg Maximum dose 5 mg	Oral	Pain score 4–6 Repeat once if required after 30 minutes to maximum dose
Oxygen	2–15 L/min, device dependent	Inhalation	Continuous
Paracetamol ^H	1000 mg	Oral	Pain score 1–10 Once only
Prochlorperazine	5 mg	Oral	Once only
	OR
	12.5 mg	IV/IM	Once only
Sodium chloride 0.9%	250 mL Maximum dose 1000 mL	IV/intraosseous	Bolus Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved

Medications with contraindications or requiring dose adjustment are marked:

^H for patients with known hepatic impairment
^R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

References

Show

Agency for Clinical Innovation. Pathway for Acute Coronary Syndrome Assessment (PACSA). Australia: NSW Health, ACI; 2022 [cited 2 Feb 2023]. Available from: https://www1.health.nsw.gov.au/pds/Pages/doc.aspx?dn=GL2019_014
Agency for Clinical Innovation. Nurse Administered Thrombolysis for ST Elevation Myocardial Infarction (STEMI). Australia: NSW HEalth; 2022 [cited 2 Feb 2023]. Available from: https://www1.health.nsw.gov.au/pds/Pages/doc.aspx?dn=PD2022_055
MIMS Australia. Clinical Resources. Australia: MIMS Australia Pty Ltd; 2022 [cited 2 Feb 2023]. Available from: https://www.mimsonline.com.au.acs.hcn.com.au/Search/Search.aspx
Beasley R, Chien J, Douglas J, et al. Thoracic Society of Australia and New Zealand oxygen guidelines for acute oxygen use in adults: 'Swimming between the flags'. Respirology. 2015 Nov;20(8):1182-91. DOI: 10.1111/resp.12620
Chadwick M. Evaluation of emergency department patients with chest pain at low or intermediate risk for acute coronary syndrome. Uptodate: Wolters Kluwer; 2018 [cited 2 Feb 2023]. Available from: https://www.uptodate.com.acs.hcn.com.au/contents/evaluation-of-patients-with-chest-pain-at-low-or-intermediate-risk-for-acute-coronary-syndrome?search=suspected%20ACS&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2
Chew DP, Scott IA, Cullen L, et al. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of acute coronary syndromes 2016. Med J Aust. 2016 Aug 1;205(3):128-33. DOI: 10.5694/mja16.00368
Jaffe A, Morrow D. Troponin testing: Clinical use. Uptodate: Wolters Kluwer; 2018 [cited 2 Feb 2023]. Available from: https://www.uptodate.com.acs.hcn.com.au/contents/troponin-testing-clinical-use?search=troponin%20testing&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
Jowett NI, Turner AM, Cole A, et al. Modified electrode placement must be recorded when performing 12-lead electrocardiograms. Postgraduate Medical Journal. 2005;81(952):122-5. DOI: 10.1136/pgmj.2004.021204
Mauro M, Nelson A, Stokes M. Troponin testing in the primary care setting. Australian Journal for General Practitioners. 2017 09/18;46:823-6. Available from: https://www.racgp.org.au/afp/2017/november/troponin-testing
National Heart Foundation Australia. Decision-making and timing considerations in reperfusion for STEMI. The Medical Journal of Australia: NHFA; 2016 [cited 2 Feb 2023]. Available from: https://www.heartfoundation.org.au/getmedia/287d4d79-b0d9-4e5c-9eea-ee2381514292/decision-making_and_timing_considerations_in_reperfusion_for_stemi-2016.pdf
NSW Health. Australian Medicines Handbook. Australia: Australian Government, NSW; 2022 [cited 13 Apr 2022]. Available from: https://amhonline.amh.net.au.acs.hcn.com.au/
Royal Flying Doctors Service (RFDS). Clinical Manual Part 3 Procedures. Version 72. Australia RFDS; 2020 [cited 2 Feb 2023]. Available from: https://files.flyingdoctor.org.au/dd/magazine/file/Part_3_-_Procedures__-_March_2020_-_Version_7.d557.pdf
Therapeutic Guidelines. Acute chest pain of possible cardiac origin. VIC, Australia Therapeutic Guidelines Limited; 2018 [cited 2 Feb 2023]. Available from: https://tgldcdp.tg.org.au.acs.hcn.com.au/viewTopic?etgAccess=true&guidelinePage=Cardiovascular&topicfile=acute-chest-pain

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Evidence informed	Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.
Collaboration	This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.
Currency	Due for review: Jan 2026. Based on a regular review cycle.
Feedback	Email ACI-ECIs@health.nsw.gov.au

ECAT home page Glossary

Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/ecat/adult/chest-pain

Chest pain

On this page

History prompts, signs and symptoms

History prompts

Signs and symptoms

Red flags

Historical

Clinical

Clinical assessment and specified intervention (A to G)

Position

Airway

Breathing

Circulation

Disability

Exposure

Fluids

Glucose

Focused assessment

Precautions and notes

Interventions and diagnostics

Specific treatment

Analgesia

Pain score 1–3 (mild)

Pain score 4–6 (moderate)

Pain score 7–10 (severe)

Fentanyl intranasal

Fentanyl IV

Morphine IV

Morphine IM

Nausea and/or vomiting

Radiology

Pathology

Medications

References