Chest Pain: EMS Review
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Transcript of Chest Pain: EMS Review
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
http://bit.ly/2o0U2NWayne Guerra MD, MBA
BP Discrepancy
http://bit.ly/hkAZE Wayne Guerra MD, MBA
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
Wayne Guerra MD, MBA
Acute Ant-Lat MI
Wayne Guerra MD, MBA
Acute Inferior MI
Wayne Guerra MD, MBA
Acute Posterior MI
http://bit.ly/2Klwk2 Wayne Guerra MD, MBA
Acute Right Ventricular MI
Wayne Guerra MD, MBA
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