Chest Pain EMS Implications

Wayne Guerra MD, MBAPorter/Littleton/Parker Adventist EMS

Pain is inevitable; suffering is optional.

Before I refuse to take your questions, I have an opening statement.Ronald Reagan

Wayne Guerra MD, MBA

Objectives

• Improve EMS History and Physical• Expand and Focus Differential Diagnosis• Review EMS Treatment• Avoid Pitfalls• Learn A Zebra or Two

Experience is something you don't get until just after you need it.

Wayne Guerra MD, MBA

The Father of Medicine

patient confidentiality

physicians record their findings and their medicinal methods

rejected the superstition and magic

460 BC to 380 BC

Wayne Guerra MD, MBA

To EMS or Not EMS?

• Private transport: 35 minutes• EMS: 39 minutes• Definitely EMS

http://heartdisease.about.com/cs/heartattacks/a/chestpainEMS.htmWayne Guerra MD, MBA

www.iTriageHealth.comWayne Guerra MD, MBA

Differential Diagnosis of Chest Pain is Vast

Possible Causes

• ACS– MI– Unstable Angina

• PE• Aortic Dissection• Esophageal Rupture• Tension Pneumothorax

Wayne Guerra MD, MBA

History

• Establishing Prevalence• Who, What, Where, How, Why• Chest pain

– Typical– Atypical (One study of 430,000 33% had no CP!)

JAMA. 283(24):3223–3229, 2000Wayne Guerra MD, MBA

“Atypical” Chest Pain

• Females• Diabetics• Elderly

– 14% in < 65 years– 21 % in 65-74 years– 32% in >= 75 years

Circulation, III: e435-e437, 2005 Wayne Guerra MD, MBA

“Atypical” Chest Pain

• 23% burning (indigestion) • 5% as sharp and stabbing• 6-9% as positional or pleuritic• 26% SOB

Arch Intern Med. 145: 65-69, 1985. Wayne Guerra MD, MBA

“Atypical” Chest Pain

• Back, shoulder, neck• Abdomen• N/V

Wayne Guerra MD, MBA

“Atypical” Chest Pain

• Diaphoresis• Syncope• Palpitations • “Weakness”• “Falls”

Wayne Guerra MD, MBA

History

• Past Medical History• Medications (Bring all into ED)

Wayne Guerra MD, MBA

History

• Past Surgical History• Recruit others for information• Recent illnesses• Social history

Wayne Guerra MD, MBA

Physical

• Vitals are vital• Heart• Lungs • Pulses• Abdomen• Neuro

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BP Discrepancy

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Diagnostics

Wayne Guerra MD, MBA

EKGGet One You Can Read!

Wayne Guerra MD, MBA

Stratergery For A Good Tracing

• Do before transport• Give pain medications if possible• Encourage patient to relax• Ensure good lead contact

Wayne Guerra MD, MBA

Importance of CVD an ACS• Second most common complaint in ED• 2-5% ACS missed

http://bit.ly/hkAZEWayne Guerra MD, MBA

EKG Mimics of MI

• Left Ventricular Hypertrophy• Early Repolarization• Acute Pericarditis• Left Ventricular Aneurysm

Wayne Guerra MD, MBA

LVH With Strain• ST elevation and depression• T wave changes

Wayne Guerra MD, MBA

Early Repolarization

Wayne Guerra MD, MBA

Acute Pericarditis

PR depression

ST ElevationWayne Guerra MD, MBA

LV Aneurysm

Wayne Guerra MD, MBA

ECG FindingAcute Pericarditis Myocardial

InfarctionEarly Repolarization

ST-segment shape Concave upward Convex upward Concave upward

Q waves Absent Present Absent

Reciprocal ST-segment changes

Absent Present Absent

Location of ST-segment elevation

Limb and precordial leads

Area of involved artery

Precordial leads

ST/T ratio in lead V6

>0.25 N/A <0.25

Loss of R-wave voltage

Absent Present Absent

PR-segment depression

Present Absent Absent

EKG Changes: Mimics of MI

Dave Sanko: ACS and 12 Lead Review Wayne Guerra MD, MBA

AMI Localization

aVF inferiorIII inferior V3 anterior V6 lateral

aVL lateralII inferior V2 septal V5 lateral

aVRI lateral V1 septal V4 anterior

Dave Sanko: ACS and 12 Lead Review Wayne Guerra MD, MBA

Acute Anterior MI

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Acute Ant-Lat MI

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Acute Inferior MI

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Acute Posterior MI

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Acute Right Ventricular MI

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Cardiac Alert

Wayne Guerra MD, MBA

Acute MI and LBBB

1) ST-segment elevation measuring 1 mm in the same direction with the QRS in any lead.2) ST-segment depression measuring 1 mm in any of the V1 through V3

leads.

http://bit.ly/2g9EcZ Wayne Guerra MD, MBA

Unstable angina

• Includes non-Q wave MI• New pattern of angina• Angina at rest• 30 day death rate: 3.5%• 30 day MI rate: 8.5%

http://bit.ly/PlrtS Wayne Guerra MD, MBA

Pulmonary Embolus

• 650,000 cases annually• 3rd most common cause of death• 1st or 2nd most common unexpected death• 10% die within 60 minutes

Wayne Guerra MD, MBA

Pulmonary EmbolusIncreased Risk

• Virchow’s Triad– Venous stasis– Hypercoagulability– Inflammation

Wayne Guerra MD, MBA

Pulmonary Embolus

• Pleuritic CP: 74%• Risk factors:

– Pregnancy and post partum– BCPs– Malignancy– Surgery– Immoblization– Inherited hypercoagulability

Wayne Guerra MD, MBA

Pulmonary Embolus

• Signs– Tachypnea (>16) 92%– Rales 58%– Tachycardia (>100) 44%– Fever (>100 ⁰F) 43%– Diaphoresis 36%– Signs of DVT 32%

Wayne Guerra MD, MBA

S1Q3T3

Wayne Guerra MD, MBA

Aortic Dissection

• Characteristic description

• Increased risk• BP differential• Murmur• Can be associated with

acute MI

Wayne Guerra MD, MBA

Aortic Dissection

• EMS treatment• ED treatment• Hospital treatment

Wayne Guerra MD, MBA

Esophageal Rupture

• Baron von Wassenaer• Boerhaave’s syndrome (Spontaneous)• Most are iatrogenic

Wayne Guerra MD, MBA

Esophageal Rupture

• Forceful vomiting• 50% have GERD• Severe chest/epigastric pain• Other sxs depending on time

Wayne Guerra MD, MBA

Esophageal Rupture

• Physical– Subcutaneous emphysema (60%)– Mackler triad (vomiting, CP, SubQ emphysema)– Tachycardia/tachypnea– Hamman sign (crunching sound over heart)– Decreased breath sounds

Wayne Guerra MD, MBA

Esophageal Rupture

• EMS Treatment– O2– IV fluids– Pain meds– Check lactate (May appear septic)

Wayne Guerra MD, MBA

Tension Pneumothorax

• One way valve• Pathophysiology

Wayne Guerra MD, MBA

Tension Pneumothorax

• Sudden CP & SOB• Tachys• Hypos• breath sounds• Tracheal deviation• JVD• Sub-Q emphysema

Wayne Guerra MD, MBA

Tension PneumothoraxEMS Treatment

• O2• Needle thoracostomy• IVFs• +/- intubation

Wayne Guerra MD, MBA

Needle Thoracostomy

• Iodine prep• 14/16 Ga catheter,

4.5cm minimum• Just superior 3rd rib 1-2

cm from sternum• Listen for hissing sound• Flutter valve or

stopcock

Wayne Guerra MD, MBA

Wayne Guerra MD, MBA

Case 1

• 32 yo female with crushing cp, sob and diaphoresis

• Meds/PMH/Soc Hx/Past Surg Hx all negative• 120/70, 90, 18, RA Sat=97%

Wayne Guerra MD, MBA

Case 1

Wayne Guerra MD, MBA

Case 1: EKG After 1 NTG

Diagnosis?Wayne Guerra MD, MBA

Prinzmetal's Angina

• Coronary artery spasm• Typically occurs at rest• 2/3rds have CAD• Spasm can be induced during angiogram• Rx with nitrates and Ca channel blockers

Wayne Guerra MD, MBA

Case 2

• 50 yo male pressure like chest pain • PMH: DM, Htn, Elevated cholesterol• Meds: Insulin, HCTZ, Tenormin, Lipitor• 130/70, 70, 18, RA Sat=96%• Exam: nl

Wayne Guerra MD, MBA

EKG with CP

Wayne Guerra MD, MBA

Pain Free After 1 NTG

Diagnosis?Wayne Guerra MD, MBA

Wellens Syndrome• Isoelectric or minimally ST followed by

concave or straight ST and a symmetrically inverted T wave

• Most common V2-V3, and V4-V6• Highly suggestive critical LAD stenosis

http://bit.ly/15RAYb

Wayne Guerra MD, MBA

Wayne Guerra MD, MBA