Medical Emergencies · patient case question
What is the appropriate immediate management?
Patient case: Chest pain during treatment in a patient with angina
Patient: Female, 65 years old
Chief Complaint: Presenting for a scheduled restoration.
Background: Stable angina for six years, hypertension, hyperlipidaemia. Medications: sublingual nitroglycerin as required, atorvastatin, losartan, aspirin 81 mg. She has brought her own nitroglycerin spray and it is in her handbag.
Vital Signs: On seating BP 142/84 mmHg · HR 78 bpm. During treatment she reports MILD central chest tightness, the same as her usual angina, with no radiation, no sweating and no shortness of breath.
Findings: Restoration in progress on tooth #30. She has complained of a persistent metallic, altered taste since her medication was changed some months ago, and of a dry mouth.
Show answer and explanation
Correct answer: D. Stop treatment, sit her upright, give oxygen, and have her take HER OWN sublingual nitroglycerin
- A. EMS is activated if the pain does NOT resolve after three doses of nitroglycerin at five-minute intervals, or if it differs from her usual pattern, or if there is radiation, diaphoresis, dyspnoea or collapse — because that is a myocardial infarction until proven otherwise. Aspirin belongs to that scenario, not to a typical anginal episode that has not yet been treated.
- B. Continuing treatment while a cardiac patient has chest pain is indefensible. The stress prolongs the ischaemia.
- C. Supine positioning with legs elevated is for SYNCOPE, where the aim is to restore cerebral perfusion. In cardiac chest pain it increases venous return and preload, worsening the oxygen demand mismatch — the opposite of what is wanted.
- D. CORRECT. For a patient with KNOWN stable angina experiencing HER USUAL pain: stop the procedure, position her comfortably UPRIGHT or semi-upright, give oxygen, and administer nitroglycerin — HER OWN, because it is prescribed to her, she knows the dose, and its potency is assured, whereas an emergency kit vial may be expired. Sublingual nitroglycerin acts within one to three minutes. Monitor vital signs and reassure.
Note: Ask every anginal patient to BRING their nitroglycerin and place it on the bracket table before starting. Two cautions: nitroglycerin is contraindicated within 24 hours of sildenafil or 48 hours of tadalafil, since the combination causes profound hypotension; and hypotension is the limiting side effect in any case, so check the blood pressure between doses.
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