Shortness of breath with a history of cardiac disease

Any person, 16 years and over, presenting with shortness of breath and who has a history of cardiac disease.

History prompts, signs and symptoms

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

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.

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 Preferably semi-reclined or upright

Airway

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 Measure SpO2 if signs of hypoxia or respiratory distress Consider oxygen if dyspnoeic, titrate oxygen to maintain SpO2 over 93%

Circulation

Assessment	Intervention
Perfusion (capillary refill, skin warmth and colour) Pulse Blood pressure Cardiac rhythm	Assess circulation Attach cardiac monitor and complete 12 lead ECG
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension	If SBP less than 90 mmHg or signs of shock present, escalate as per local CERS protocol immediately
IVC and/or pathology	Insert IV cannula, if trained If unable to obtain IV access, consider intraosseous, if trained See pathology section
Raised JVP and/or peripheral oedema	If audible respiratory crepitations and raised JVP and/or peripheral oedema AND if SBP over 100 mmHg: Give glyceryl trinitrate: tablet 300 microg sublingually. Repeat once after 5 minutes, if SBP is over 100 mmHg. Maximum dose 600 microg or spray 400 microg (1 spray) sublingually. Repeat once after 5 minutes, if SBP is over 100 mmHg. Maximum dose 800 microg and give furosemide (Frusemide) 40 mg IV once only Escalate as per local CERS protocol for consideration of further glyceryl trinitrate if patient remains hypertensive

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 Consider fluid restriction
NBM	Consider clear fluids or NBM based on red flags and clinical severity
Nausea and/or vomiting	If present, see nausea and/or vomiting section

Glucose

Assessment	Intervention
BGL	Measure BGL, if clinically indicated If less than 4 mmol/L, consider hypoglycaemia protocol

Focused assessment

Complete a respiratory focused assessment.

Consider cardiovascular focused assessment.

Precautions and notes

• Investigating and managing precipitating factors is recommended for all patients with acute heart failure. Common causes include:
  • AMI
  • pulmonary embolism
  • arrhythmia
  • infection
  • anaemia
  • thyroid disorder
  • acute renal failure
• Patients should be assessed for concurrent use of other glyceryl trinitrate preparations via routes other than oral, i.e. rectogesic.

Interventions and diagnostics

Specific treatment

If ineffective respiratory effort, consider non-invasive ventilation (NIV) where available and escalate as per local CERS protocol if required.

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Analgesia

If pain score 1–6 (mild–moderate), give:

• paracetamol 1000 mg orally once only
• and/or ibuprofen 400 mg orally once only.

If severe pain present, give analgesia and escalate as per local CERS protocol.

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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.

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Radiology

• CXR

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Pathology

• FBC, UEC, LFT, troponin
• Warfarinised: INR
• Temp less than 35°C, or 38.5°C and over: take two sets of blood cultures from two separate sites

Medications

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

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.

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