Chest Pain: EMS Review
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Transcript of Chest Pain: EMS Review
![Page 1: Chest Pain: EMS Review](https://reader036.fdocuments.in/reader036/viewer/2022062705/556db775d8b42aed2e8b47da/html5/thumbnails/1.jpg)
Chest Pain EMS Implications
Wayne Guerra MD, MBAPorter/Littleton/Parker Adventist EMS
Pain is inevitable; suffering is optional.
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Before I refuse to take your questions, I have an opening statement.Ronald Reagan
Wayne Guerra MD, MBA
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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
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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
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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
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www.iTriageHealth.comWayne Guerra MD, MBA
Differential Diagnosis of Chest Pain is Vast
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Possible Causes
• ACS– MI– Unstable Angina
• PE• Aortic Dissection• Esophageal Rupture• Tension Pneumothorax
Wayne Guerra MD, MBA
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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
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“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
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“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
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“Atypical” Chest Pain
• Back, shoulder, neck• Abdomen• N/V
Wayne Guerra MD, MBA
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“Atypical” Chest Pain
• Diaphoresis• Syncope• Palpitations • “Weakness”• “Falls”
Wayne Guerra MD, MBA
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History
• Past Medical History• Medications (Bring all into ED)
Wayne Guerra MD, MBA
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History
• Past Surgical History• Recruit others for information• Recent illnesses• Social history
Wayne Guerra MD, MBA
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Physical
• Vitals are vital• Heart• Lungs • Pulses• Abdomen• Neuro
http://bit.ly/2o0U2NWayne Guerra MD, MBA
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BP Discrepancy
http://bit.ly/hkAZE Wayne Guerra MD, MBA
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Diagnostics
Wayne Guerra MD, MBA
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EKGGet One You Can Read!
Wayne Guerra MD, MBA
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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
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Importance of CVD an ACS• Second most common complaint in ED• 2-5% ACS missed
http://bit.ly/hkAZEWayne Guerra MD, MBA
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EKG Mimics of MI
• Left Ventricular Hypertrophy• Early Repolarization• Acute Pericarditis• Left Ventricular Aneurysm
Wayne Guerra MD, MBA
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LVH With Strain• ST elevation and depression• T wave changes
Wayne Guerra MD, MBA
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Early Repolarization
Wayne Guerra MD, MBA
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Acute Pericarditis
PR depression
ST ElevationWayne Guerra MD, MBA
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LV Aneurysm
Wayne Guerra MD, MBA
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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
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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
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Acute Anterior MI
Wayne Guerra MD, MBA
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Acute Ant-Lat MI
Wayne Guerra MD, MBA
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Acute Inferior MI
Wayne Guerra MD, MBA
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Acute Posterior MI
http://bit.ly/2Klwk2 Wayne Guerra MD, MBA
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Acute Right Ventricular MI
Wayne Guerra MD, MBA
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Cardiac Alert
Wayne Guerra MD, MBA
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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
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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
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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
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Pulmonary EmbolusIncreased Risk
• Virchow’s Triad– Venous stasis– Hypercoagulability– Inflammation
Wayne Guerra MD, MBA
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Pulmonary Embolus
• Pleuritic CP: 74%• Risk factors:
– Pregnancy and post partum– BCPs– Malignancy– Surgery– Immoblization– Inherited hypercoagulability
Wayne Guerra MD, MBA
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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
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S1Q3T3
Wayne Guerra MD, MBA
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Aortic Dissection
• Characteristic description
• Increased risk• BP differential• Murmur• Can be associated with
acute MI
Wayne Guerra MD, MBA
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Aortic Dissection
• EMS treatment• ED treatment• Hospital treatment
Wayne Guerra MD, MBA
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Esophageal Rupture
• Baron von Wassenaer• Boerhaave’s syndrome (Spontaneous)• Most are iatrogenic
Wayne Guerra MD, MBA
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Esophageal Rupture
• Forceful vomiting• 50% have GERD• Severe chest/epigastric pain• Other sxs depending on time
Wayne Guerra MD, MBA
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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
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Esophageal Rupture
• EMS Treatment– O2– IV fluids– Pain meds– Check lactate (May appear septic)
Wayne Guerra MD, MBA
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Tension Pneumothorax
• One way valve• Pathophysiology
Wayne Guerra MD, MBA
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Tension Pneumothorax
• Sudden CP & SOB• Tachys• Hypos• breath sounds• Tracheal deviation• JVD• Sub-Q emphysema
Wayne Guerra MD, MBA
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Tension PneumothoraxEMS Treatment
• O2• Needle thoracostomy• IVFs• +/- intubation
Wayne Guerra MD, MBA
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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
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Wayne Guerra MD, MBA
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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
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Case 1
Wayne Guerra MD, MBA
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Case 1: EKG After 1 NTG
Diagnosis?Wayne Guerra MD, MBA
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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
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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
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EKG with CP
Wayne Guerra MD, MBA
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Pain Free After 1 NTG
Diagnosis?Wayne Guerra MD, MBA
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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
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Wayne Guerra MD, MBA