SILVER CROSS EMS EMD CE

FEBRUARY 2012

Cardiovascular: ischemia (AMI or angina) pericarditis (irritation of pericardium) thoracic aortic dissection

Respiratory: PE (pulmonary embolism) pneumothorax pneumonia pleural irritation hyperventilation (anxiety)

Gastrointestinal: cholecystitis (gall bladder/gallstones)

pancreatitis hiatal hernia (part of stomach pushes through diaphragm)

esophageal disease/GERDpeptic ulcers dyspepsia (indigestion)

Musculoskeletal: chest wall syndrome (inflamed chest wall)

costochondritis (inflamed rib cartilage)

herpes zoster (shingles)chest wall trauma chest wall tumors

There are literally dozens of illnesses, injuries and conditions that can cause chest pain.

Knowing common signs, symptoms and patient presentations can help you differentiate between different kinds of chest pain.

Bottom Line: If you are ever not sure what kind of chest pain you are dealing with, treat it as cardiac.

•CAUSE•ONSET OF PAIN •CHARACTERISTIC OF PAIN•LOCATION OF PAIN•HISTORY •ASSOCIATED Signs & Symptoms•AGGRAVATING FACTORS•RELIEVING FACTORS

All are further explained in following slides

QUESTIONS TO HELP DIFFERENTIATE CHEST PAIN

What were the doing when the pain started?Constant?Sudden?How Long has it been going on?

How severe is it? 1-10 scale with 10 being the worst

Is there anything that makes it better or worse?◦ Movement or Exertion (might be muscular or

cardiac)◦ Deep breaths or coughing (might be lung or

muscular)◦ Rest (could be angina or muscular)◦ Position (could be muscular)◦ Pain relievers or Antacids (usually not cardiac) ◦ Stress (may be anxiety or cardiac)

PLEURITIC (sharp pain with inhalation)

SPASMODIC (like a spasm)

TIGHTNESS OR HEAVINESS

PRESSURE- OPPRESSIVE

SHARP/LOCALIZED (easy to pinpoint)

VISCERAL (hard to pinpoint)/BURNING

TEARING / EXCRUCIATING

SUBSTERNAL CENTER OR ACROSS CHEST LATERAL CHEST LOCALIZED OVER INVOLVED AREA LOWER CHEST/EPIGASTRIC RADIATES TO JAW, NECK, BACK OR ARM VAGUE

AGE PREVIOUS EPISODES UPPER RESPIRATORY INFECTION/FEVER TRAUMA STRESS EMOTIONAL UPSET CARDIAC DISEASE – HIGH BLOOD

PRESSURE, CORONARY ARTERY DISEASE, ANGINA

DYSPNEA (Difficulty Breathing) DIAPHORESIS (Sweating), COOL OR CLAMMY SKIN NAUSEA / VOMITING ALTERED MENTAL STATUS (Including Anxiety and

Restlessness) /WEAKNESS /LIGHTHEADEDNESS / SYNCOPE (Fainting)

DECREASED OR ABNORMAL BREATH SOUNDS CYANOSIS (Bluish tint to skin from lack of oxygen) HEMOPTYSIS (coughing up blood) PULSATING ABD MASS ABDOMINAL or BACK PAIN PAIN WITH PALPATION RASH OR LESIONS ABNORMAL BLOOD PRESSURE

Sudden onset of painthat does not go away with rest or analgesicMedication. Pain will beSubsternal (center of chest, behind breast bone)and sometimes radiate to left jaw, back or shoulder.

Shortness of breath Skin color will be poor with sweating Victim may be nauseated, lightheaded or

dizzy Pain description usually varies from a

pressure/heaviness to sharp or crushing Pain may be relieved with Nitroglycerin if

patient has been prescribed for Angina pain

WHEN IN DOUBT, ASSUME HEART ATTACK!

The next slide shows a variety of conditions that may cause chest

pain and some of the other associated signs and symptoms

for your review.

COMPARISON OF CHEST PAINCAUSE ONSET OF PAIN CHARACTERISTIC OF PAIN LOCATION OF PAIN HISTORY PAIN WORSENED BY PAIN RELIEVED BY OTHER

Acute MI Sudden onset, Pressure, burning, aching, across chest, may 40-70 years, movement, anxiety nothing- no movementShortness of breath,duration >30-60 mins. tightness, choking radiate to jaw and neck, may or maynot have position or breathing diaphoresis, anxiety,

down arms and back hx of angina Medication-MS weakness

Angina sudden onset, lasts aches, squeezing, choking, substernal,may radiate to Hx of angina, circum- lying down, eating, stress,rest, oxygen, nitro unstable angina-minutes heaviness, burning jaw, neck, arms or back stances precipitating, cold weather, exertion, appears at rest

pain characteristics, angerrelieved by nitro

Dissecting sudden onset excruciating, tearing pain center of chest, radiates non-specific, pain nothing BP difference betweenAneurysm into the back or abdomen usually worse at onset R & L arms

Pericarditis most common- suddensharp, knife-like retrosternal, may radiate Hx of URI or fever deep breats, chest move-sitting upright, leaning friction rub, paradoxical onset to the neck & left arm ment, swallowing forward pulse

Pneumonia gradual, varies pleuritic, sharp localized over affected URI, elevated temp breathing, laying position, meds dyspnea,decrease area down or abn. BS,

decreased BP

Pneumothorax sudden onset tearing, pleuritic lateral chest (AS) no hx-spontaneous respiration dyspnea, increased HR,chest trauma chest wall movement decreased BS, tracheal

deviation (UAS)

Pulmonary Embolussudden onset crushing-most common lateral chest phlebitis, a fib respiration holding breath cyanosis, dyspnea,can mimic AMI or anginal smoking, BCP, post sur- hemoptysis

gical, prolonged inactivity "impending doom"

Gastrointestinal sudden onset gripping, burning, spasmodic lower substernal, upper may or maynot be eating or ETOH, supine antacids, bland dietor constant abdomenal present position

Hiatal hernia sudden onset sharp, severe lower chest, upper abdomenmay or maynot be heavy meals, supine mild activity (walking),present position bland diet, antacids,

semi-fowlers or sittingupright

Hyperventilation / sudden onset vague or diffuse c/o CP vague hyperventilation, increased RR reduce anxiety, "can be talked down"anxiety stress, emotional upset decrease RR

The heart must receive a constant supply of oxygen or it will die.

The heart receives its oxygen through a complex system of coronary arteries.◦ These arteries may narrow as a result of

atherosclerosis.

◦ Progressive atherosclerosis can cause angina pectoris, heart attack, and cardiac arrest.

Results when one or more of the coronary arteries is completely blocked

Two causes of coronary artery blockage:◦ Severe

atherosclerosis

◦ Blood clot

Your protocol will be changing to include the administration of aspirin to victims that may be having a heart attack.

Why, you ask? Read on…… Most heart attacks develop when a cholesterol-laden plaque in

a coronary artery ruptures. Relatively small plaques, which produce only partial blockages, are the ones most likely to rupture. When they do, they attract platelets to their surface. Platelets are the tiny blood cells that trigger blood clotting. A clot, or thrombus, builds up on the ruptured plaque. As the clot grows, it blocks the artery. If the blockage is complete, it deprives a portion of the heart muscle of oxygen. As a result, muscle cells die — and it’s a heart attack.

Aspirin helps by inhibiting platelets. Only a tiny amount is needed to inhibit all the platelets in the bloodstream; in fact, small amounts are better than high doses. But since the clot grows minute by minute, time is of the essence. Chewed Aspirin can work in 5-15 minutes and can really make a difference in patient outcome.

Most be aspirin or aspirin containing product.

Key questions will include:

Descriptions of pain and associated S & S

Availability of aspirin on sceneAllergies to aspirinBleeding disorders or

recent GI bleed

Other pain relievers do not have the same affect!

Pre-arrival Instructions: Calm, reassure patient Let them assume

comfortable position and loosen tight clothing

If they have medications for chest pain follow their doctors orders

If there are no contraindications, advise them to chew 1 adult or 4 low dose (baby) aspirins which they may follow with a few sips of water

The final revisions are being made and will be going to Dr. Dave for approval soon. Watch for future announcements and flipchart review sessions to go over the changes.