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Understanding Chest Pain

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Understanding Chest Pain

• Chest Pain is a broad and purposefully vague term; where do we consider the chest?   Solely the front of the body?  Under the arms?  Between the shoulder blades?

• Pain from the chest can present anywhere in the upper torso and, furthermore, can radiate(spread) or refer (be felt elsewhere) in different places.

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Understanding Chest Pain

• And how does the casualty describe the pain?  A vice-like crushing pain?  A dull, nagging ache or a sharp, focused stabbing pain?  Is it constant or does it come and go?  Is it continual or is it brought on by exercise or some other stimulus?

• As well as the wide range of signs or symptoms which may present, Chest Pain may indicate as a variety of conditions, from trivial to life-threatening:

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Cardiovascular

• Angina Pectoris • Myocardial infarction ("heart attack")• Dissecting aortic aneurysm• Heart failure• Pericarditis and cardiac tamponade• Arrhythmia - atrial fibrillation and a number

of other arrhythmias can cause chest pain.

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Pulmonary

• Pulmonary embolism• Pneumonia• Hemothorax• Pneumothorax and Tension pneumothorax• Pleurisy - an inflammation of the pleura

(lining of the chest cavity) which can cause painful respiration

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Gastro-Intestinal

• Heartburn• Indigestion• Hiatus hernia - a protrusion of the upper

part of the stomach into the thorax through a tear or weakness in the diaphragm.

• Neuromuscular disorders of the oesophagus

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Chest Wall

• Chest wall injury• Nerve damage• Precordial catch syndrome - another

benign and harmless form of a sharp, localised chest pain often mistaken for heart disease

• Breast conditions• Tuberculosis

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Physiological

• Panic attack• Anxiety• Clinical depression• Hypochondria

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Understanding Chest Pain

• While the list of possible conditions may be intimidating and diagnosis outside of a hospital my be difficult we shall see that there are common themes of treatment for all.

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The Spectrum of Cardiac Conditions

• Many cardiac conditions are functions of lifestyle; long term health problems which lead to atherosclerotic or arteriosclerotic problems or high blood pressure (hypertension).   The most significant factors include:

• Smoking• Alcohol• Poor diet

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The Spectrum of Cardiac Conditions

• Lack of exercise / sedentary work or lifestyle

• High stress• Age• Being male• Family history• Diabetes or other causative medical

conditions

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The Spectrum of Cardiac Conditions

• With this in mind, knowing your casualty will already help you form an opinion of what the cause of their chest pain might be; fit young, healthy people tend not to have cardiac disease! 

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The Spectrum of Cardiac Conditions

• The spectrum of cardiac conditions which are commonly found include both acute (severe and sudden onset) and chronic (long term development) medical conditions.  This article looks at:

• Angina• Heart Attack• Heart Failure• Aortic Aneurysm

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Angina Pectoris

• Chest pain does not always mean a person is having a heart attack (myocardial infarction or "MI").  Angina is a chronic condition and typically a symptom of atherosclerotic coronary disease.  Narrowing of the coronary arteries reduce the amount of oxygen the heart receives.  

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Angina Pectoris

• In normal situations or at rest the patient feels no discomfort as the heart is receiving enough oxygen to meet it's normal demand.

• During periods of exercise or stress, when the heart is working harder, the oxygen demand increases but is not able to to be met.   It is during these moments that patients will exhibit chest pain including:

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Angina Pectoris

• Central chest pain• May radiate across the chest or into the

jaw, left arm or throat• The pain usually lasts from 3 to 8 minutes

but rarely above 15 minutes1.• Pain is usually eased with rest (as the

hearts oxygen demand reduces) or administration of the patient's Glyceryl Trinitrate medicine.

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Angina Pectoris

• Angina Treatment (2,3)• 2 puffs of GTN spray under the tongue –

pain should ease within 5 minutes.• If there is no improvement after 5 minutes,

the casualty should administer a further 2 puffs.

• If there is no improvement after a further 5 minutes, the casualty should administer a third does of 2 puffs.

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Angina Pectoris

• If there is no improvement after a further 5 minutes (15 minutes in total since first administration) assume Heart Attack.

• Call 999 and encourage the casualty to chew 300mg aspirin.

•  Resting the patient and positioning them seated, or sat on the floor against a wall, together with prompt medication usually eases the condition.  This is Stable Angina.

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Angina Pectoris

• Unstable Angina is characterised by the signs and symptoms above but is triggered by progressively less exercise or fewer stimuli.   If untreated, Unstable Angina can lead to an MI.

• If in doubt - ASSUME IT IS A HEART ATTACK 

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Heart Attack

• Where angina is caused by a restriction of the cardiac vessels, a heart attack (MI) is usually caused by a complete or partial blockage; typically a piece of atherosclerotic plaque that has detached from the vessel wall during a moment of stress or exercise and become lodged within a cardiac artery.  

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Heart Attack

• Alternatively, the build up of plaque can be so great the long term ischemia causes irreparable damage to the affected part of the heart.

• In either situation, the lack of oxygen causes death of the muscle tissue which interrupts the normal electrical activity of the heart, resulting in Cardiac Arrest.

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Heart Attack

• Cardiac Arrest is a medical emergency where death is imminent if decisive action is not taken quickly.   Time is the most critical factor in a successful resuscitation.  The casualty needs rapid defibrillation with CPR provided in the mean time to maintain oxygen supply to the brain.  If defibrillation is not available, death is inevitable.  

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Heart Attack

• When unexpected Cardiac Arrest leads to to death, this is called Sudden Cardiac Death.  

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Signs & Symptoms

• The conscious casualty may present a number of symptoms; the onset of symptoms is usually gradual, over several minutes, and rarely instantaneous.

• Chest pain is the most common symptom of acute MI and is often described as a sensation of tightness, pressure, or squeezing.

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Signs & Symptoms

• Pain radiates most often to the left arm, but may also radiate to the lower jaw, neck, right arm, back, or epigastrium,where it may mimic heartburn.  

• Other symptoms include excessive sweating (diaphoresis) weakness, light-headedness, nausea, vomiting and palpitations.  

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Signs & Symptoms

• These symptoms are likely to be induced by a massive surge of catecholamines from the sympathetic nervous systemwhich occurs in response to pain and the haemodynamic abnormalities that result from cardiac dysfunction. 

• Due to a lack of oxygen reaching the brain (inadequate cerebral perfusion) unconsciousness follows.

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Treatment

• The conscious casualty should be sat down against something they can rest on; traditionally anyone exhibiting breathing problems or chest pain will not want to lie down.

• Bringing their knees up is said to reduce strain on the heart and increase perfusion to a marginal degree.

• If Oxygen is available it should be administered now.

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Treatment

• If the casualty has their own medication, they should be assisted to administer it.

• If they do not have their medication they should chew a 300mg aspirin or place a soluble aspirin on the tongue - they should not swallow the aspirin.

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Treatment

• Encouraging the casualty to chew - or allow the soluble aspirin to dissolve in the mouth - will allow the aspirin to be absorbed through the mucous membrane of the cheeks, allowing the drug to enter the blood stream much quicker than if it were swallowed.

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Treatment

• If a defibrillator is available, rapid defibrillation takes priority over attempted CPR.  The defibrillator pads should be applied to the casualty as soon as possible and the defibrillator activated, even if the casualty is conscious and breathing; the defibrillator will be able to monitor the heart rhythm.  There is no danger in applying a defibrillator to a conscious person prior to cardiac arrest.

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Treatment

• If the casualty becomes unconscious, and/or if there is any doubt that their breathing is not normal  the casualty should be resuscitated in line with current, national protocols. (4)

• If the airway is compromised or ventilations are difficult, chest compressions take priority.

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Treatment

• Remember:  Defibrillation takes priority over CPR if both are available

• Chest compressions take priority over ventilations if necessary

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Heart Failure

• Heart failure is a typically chronic condition characterised by reduced cardiac output - the rate and volume of blood circulated by the heart.  This can be caused by any of the heart diseases mentioned above but also by:

• Other heart diseases such as myocarditis ( myo= muscle, card= cardiac, itis= inflamation)

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Heart Failure

• Hypertension• Heart valve abnormalities such as leaking

or reverse flow back into the chambers• Arrhythmias; ineffective heart rhythms• Cardiac tamponade - a build up of fluid in

the sac surrounding the heart, inhibiting effective contraction and relaxation of the heart muscle preventing the ventricles from filling fully with blood.

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Heart Failure

• When the pumping function of the left ventricle (which supplies the aorta with oxygenated blood to the rest of the body) cannot keep up with the input from the left atrium (bringing freshly oxygenated blood from the lungs via the pulmonary veins) the heart attempts two compensate by two possible mechanisms:

• Increase in heart rate• Increase in size of the left ventricle

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Heart Failure

• These compensatory mechanisms are not sustainable in the long term.  Heart failure may occur in the left ventricle independently or in both ventricles.   Left ventricular failure, unable to keep up with the input from the pulmonary veins, forces blood to back up into the alveoli of the lungs causingpulmonary oedmea - fluid leaking into the lungs. 

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Heart Failure

• Failure of both ventricles can impair blood flow leading to reduced systemic perfusion which may manifest as weakness, confusion, drowsiness and low blood pressure (5).

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Signs & Symptoms

• Shortness of breath - typically occurring when lying and eased by sitting upright.

• Sometimes with a dry cough.• Fine crackles or wheezing on inhalation• Frothy, pink sputum• Distended jugular veins as a result of

increased venous pressure

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Signs & Symptoms

• Swollen ankles may indicate right sided heart failure

• Pale or cyanosed skin• Agitation or restlessness• Fast heart rate and breathing, high blood

pressure

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Treatment

• Encourage the casualty to sit upright• Assess the patient for signs and

symptoms listed above• Be reassuring; stress and anxiety of

breathing problems cause a viscious feedback loop

• Gather a history of the patient - known medical conditions, medications...

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Treatment

• Encourage the patient to administer their medication

• Contact the emergency services

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Aortic Aneurism

• An aortic aneurism is a weakening and subsequent widening of the aorta - the main artery which leaves the heart to transport oxygenated blood to the body - typically caused by uncontrolled high blood pressure. 

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Aortic Aneurism

• A dissecting aneurism occurs when the inner layers of the aorta become separated allowing blood, under high pressure, to leak in between the layers further increasing the risk of rupture.  A ruptured aorta will lead to almost instant death due to the vast amounts of uncontrolled internal bleeding.

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Aortic Aneurism

• An aortic aneurism may be very difficult to identify in a pre-hospital setting without equipment and the signs and symptoms may not initially be easy to differentiate from an MI but there are a number of 'classic' characteristics which may be present:

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Aortic Aneurism

• The pain from an MI is often preceded by other symptoms (see above), becoming more severe with time and often described as a 'crushing pressure' rather than a 'stabbing' pain.

• The sharp, stabbing pain of an aortic aneurism is usually abrupt and without additional symptoms and does not abate, nor is it relived with rest.

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Aortic Aneurism

• Pain is typically felt in the back, between the shoulder blades.  This can occur in an MI but much more rarely.

• If you have equipment available there may be a difference in blood pressure on each arm or it may be difficult to detect a pulse in the lower limbs compared with the arms.

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Treatment

• Arrange transport to hospital immediatly

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Conclusions

• Chest Pain can mean different things to different people so to attempt to identify the causes we need to know what to look for as the conditions sometimes present recognisable features that have been discussed in this powerpoint.