Target:
Door to balloon 90min
Criteria Time:
Chest pain within 12hrs (or worsened within 12hrs)
ECG:
ST elevation MI (2 contiguous: 1mm Limb or 2mm Chest leads)
New LBBB.
(Posterior MI do posterior leads and discuss with LGI)
Actions:
Resuscitate as required
Contact PPCI team @ LGI (Mobile No. up in Resus)
Arrange blue light (P1) ambulance to LGI
Medication:
Prasagrel 60mg if – no previous CVA
Ticagrelor 180mg if previous CVA and Aspirin 300mg
Anti-coagulated Discuss with PPCI team
Aortic Dissection (AD), is uncommon (1:980 non-traumatic chest pain) but is…Rapidly FATAL! However, is testable for 80% if recognised early, unfortunately recognising aortic dissection is difficult with a clinician pickup rate of 15-43%.
Read more
It’s essential any Modifiable causes are treated, these include:
“Early cardioversion is not recommended without appropriate anticoagulation or transoesophageal echocardiography if AF duration is longer than 24 h, or there is scope to wait for spontaneous cardioversion.”
In reality risks increase beyond 12hrs from onset, and those reverted in ED will often return to AF by the time they get to AF clinic follow up.
Arrhythmia clinic is for patients with newly diagnosed and symptomatic AF/SVT (if the patient is not symptomatic they should be followed up through their GP).
It should be remembered that patients will be seen after at least 6 weeks so anticoagulation decisions should not be delayed for clinic.
Based primarily on:
EMbeds clinical quick guide
Last evidence review: October 2026
Suggested next review: October 2026
This is a clinical support guide and does not replace clinical judgement, current CHFT medicines guidance or specialist advice.
Adult ED Management – RCUK 2025
Sinus tachycardia is usually compensatory — identify and treat the cause. Do NOT cardiovert sinus tachycardia.
Cardiac monitor
BP and SpO₂
12-lead ECG
IV access
Bloods as clinically indicated: FBC
U&E / Mg²⁺ / Ca²⁺
glucose
troponin where indicated
other investigations directed by likely cause
Give oxygen only if SpO₂ <94%, unless an alternative target is appropriate.
Sepsis/Hypovolaemia/Haemorrhage
Pain/Anxiety
Hypoxia
Fever
PE
ACS/Heart failure
Thyrotoxicosis
Drugs/Withdrawal
Pregnancy
Do not attempt to normalise an appropriate sinus tachycardia with anti-arrhythmics or electrical cardioversion.
> SHOCK: Hypotension with evidence of impaired tissue perfusion.
> SYNCOPE: Especially with severe or ongoing hypotension.
> MYOCARDIAL ISCHAEMIA: Ongoing chest pain and/or significant ischaemic ECG changes.
> SEVERE HEART FAILURE: Particularly pulmonary oedema.
> IMMEDIATELY POST-ROSC
> AF → Maximum defibrillator output
> Flutter / SVT → 70–120 J
> VT with pulse → 120–150 J
Escalate subsequent shocks where appropriate.
Do not treat physiological sinus tachycardia as an arrhythmia.
Do not delay appropriate treatment while attempting to prove SVT.
Always consider pre-excited AF.
Give magnesium and correct the underlying problem.
Confirm the machine is marking the R waves before delivering the shock.
Re-check SYNC after each shock — some defibrillators automatically revert out of synchronised mode.
Consider admission / cardiology assessment for:
Patients with uncomplicated successfully terminated SVT may be suitable for discharge following senior review, appropriate investigation and follow-up depending on the clinical circumstances.
Based primarily on:
EMbeds clinical quick guide
Last evidence review: September 2026
Suggested next review: September 2027
This is a clinical support guide and does not replace clinical judgement, current CHFT medicines guidance or specialist advice.
First take a good history, not ALL chest pain needs to be investigated as ACS. However, its worth noting older patients and women are more likely to have atypical presentations. Be wary that some patients with negative troponin give a history of Unstable Angina and therefore require admission.
Read more: Acute Coronary Syndrome (ACS) – 2025
Anticoagulated with a DOAC, or with Warfarin (with a therapeutic INR),
Direct admissions to CCU
Patients with ST Elevation (if not accepted for primary PCI) or those with CP + new ST Depression should be discussed with a local Cardiologist and come directly to CCU.
As it is difficult to be prescriptive for every other circumstance, a discussion with a senior/cardiologist may be worthwhile in order to best manage and place your patient within the hospital.
Patients where MI is excluded
If patients do exit the pathway (no new symptoms, no new ECG ischemia and troponins that meet the exit criteria to exclude an MI), two other important possibilities still require consideration:
Vascular surgery has been reconfigured across etc region. The vascular oncall will be based at BRI 24/7.
Multiple pathways have been developed below to help guide appropriate use – full guide HERE
Some patients benefit from control of bleeding using embolization techniques, which is a procedure performed by an Interventional Radiologist.
Patients should be treated in their receiving hospital to the maximum of that hospital’s capability, where at all possible. When all local treatment options have been exhausted, the patient should be discussed with one of the Arterial Centres (BRI) with a view to transfer for ongoing management by IR techniques.
Access is very limited to this clinic. It is envisioned by WYVas that access to UVAC for ED patients will be arranged through direct (telephone) referral to either:
Unfortunately the the normal pathway for investigation of PE performs poorly in pregnancy RCOG have the following pathway
There are several terms commonly used “Accelerated Hypertension”, “Hypertensive Emergency”, “Malignant Hypertension”. They all have a very similar definition (ESC/ESH, NICE, ACEP)
Patient has both:
Mortality has improved in recent years with 5yr survival of 80% if treated. However, untreated average life expectancy is 24 months.
Patients presenting with AHF have a high mortality 4-10% in-hospital and 25-30% at 1yr, and 45% if re-admitted. So rapid diagnosis a treat is essential.
there are many triggers for AHF, which if recognized and treated with help improve outcomes
Treat The Cause!: If you can identify the trigger treat it it will in turn improve the AHF. (e.g. AMI, Arrythmia(Tachy/Brady), Massive PE)
Metanalysis suggests early NIV may reduce need for intubation and improve mortality
