Chest Pain EMS Implications Wayne Guerra MD, MBA Porter/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

Improve EMS History and Physical

Expand and Focus Differential Diagnosis

Review EMS Treatment

Avoid Pitfalls

Learn A Zebra or Two

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.htm Wayne Guerra MD, MBA

Private transport: 35 minutes

EMS: 39 minutes

Definitely EMS

www.iTriageHealth.com Wayne 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

ACS

MI

Unstable Angina

PE

Aortic Dissection

Esophageal Rupture

Tension Pneumothorax

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, 2000 Wayne Guerra MD, MBA

Establishing Prevalence

Who, What, Where, How, Why

Chest pain

Typical

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

“ 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

Females

Diabetics

Elderly

14% in < 65 years

21 % in 65-74 years

32% in >= 75 years

“ 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

23% burning (indigestion)

5% as sharp and stabbing

6-9% as positional or pleuritic

26% SOB

“ Atypical” Chest Pain Back, shoulder, neck Abdomen N/V Wayne Guerra MD, MBA

Back, shoulder, neck

Abdomen

N/V

“ Atypical” Chest Pain Diaphoresis Syncope Palpitations “ Weakness” “ Falls” Wayne Guerra MD, MBA

Diaphoresis

Syncope

Palpitations

“ Weakness”

“ Falls”

History Past Medical History Medications (Bring all into ED) Wayne Guerra MD, MBA

Past Medical History

Medications (Bring all into ED)

History Past Surgical History Recruit others for information Recent illnesses Social history Wayne Guerra MD, MBA

Past Surgical History

Recruit others for information

Recent illnesses

Social history

Physical Vitals are vital Heart Lungs Pulses Abdomen Neuro http://bit.ly/2o0U2N Wayne Guerra MD, MBA

Vitals are vital

Heart

Lungs

Pulses

Abdomen

Neuro

BP Discrepancy http://bit.ly/hkAZE Wayne Guerra MD, MBA

Diagnostics Wayne Guerra MD, MBA

EKG Get 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

Do before transport

Give pain medications if possible

Encourage patient to relax

Ensure good lead contact

Importance of CVD an ACS Second most common complaint in ED 2-5% ACS missed http://bit.ly/hkAZE Wayne Guerra MD, MBA

Second most common complaint in ED

2-5% ACS missed

EKG Mimics of MI Left Ventricular Hypertrophy Early Repolarization Acute Pericarditis Left Ventricular Aneurysm Wayne Guerra MD, MBA

Left Ventricular Hypertrophy

Early Repolarization

Acute Pericarditis

Left Ventricular Aneurysm

LVH With Strain ST elevation and depression T wave changes Wayne Guerra MD, MBA

ST elevation and depression

T wave changes

Early Repolarization Wayne Guerra MD, MBA

Acute Pericarditis PR depression ST Elevation Wayne Guerra MD, MBA

LV Aneurysm Wayne Guerra MD, MBA

EKG Changes: Mimics of MI Dave Sanko: ACS and 12 Lead Review Wayne Guerra MD, MBA ECG Finding Acute Pericarditis Myocardial Infarction Early 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

AMI Localization aVF inferior III inferior V 3 anterior V 6 lateral aVL lateral II inferior V 2 septal V 5 lateral aVR I lateral V 1 septal V 4 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 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 V 1 through V 3 leads. http://bit.ly/2g9EcZ Wayne Guerra MD, MBA

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 V 1 through V 3

leads.

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

Includes non-Q wave MI

New pattern of angina

Angina at rest

30 day death rate: 3.5%

30 day MI rate: 8.5%

Pulmonary Embolus 650,000 cases annually 3 rd most common cause of death 1 st or 2 nd most common unexpected death 10% die within 60 minutes Wayne Guerra MD, MBA

650,000 cases annually

3 rd most common cause of death

1 st or 2 nd most common unexpected death

10% die within 60 minutes

Pulmonary Embolus Increased Risk Virchow’s Triad Venous stasis Hypercoagulability Inflammation Wayne Guerra MD, MBA

Virchow’s Triad

Venous stasis

Hypercoagulability

Inflammation

Pulmonary Embolus Pleuritic CP: 74% Risk factors: Pregnancy and post partum BCPs Malignancy Surgery Immoblization Inherited hypercoagulability Wayne Guerra MD, MBA

Pleuritic CP: 74%

Risk factors:

Pregnancy and post partum

BCPs

Malignancy

Surgery

Immoblization

Inherited hypercoagulability

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

Signs

Tachypnea (>16) 92%

Rales 58%

Tachycardia (>100) 44%

Fever (>100 ⁰F) 43%

Diaphoresis 36%

Signs of DVT 32%

S1Q3T3 Wayne Guerra MD, MBA

Aortic Dissection Characteristic description Increased risk BP differential Murmur Can be associated with acute MI Wayne Guerra MD, MBA

Characteristic description

Increased risk

BP differential

Murmur

Can be associated with acute MI

Aortic Dissection EMS treatment ED treatment Hospital treatment Wayne Guerra MD, MBA

EMS treatment

ED treatment

Hospital treatment

Esophageal Rupture Baron von Wassenaer Boerhaave’s syndrome (Spontaneous) Most are iatrogenic Wayne Guerra MD, MBA

Baron von Wassenaer

Boerhaave’s syndrome (Spontaneous)

Most are iatrogenic

Esophageal Rupture Forceful vomiting 50% have GERD Severe chest/epigastric pain Other sxs depending on time Wayne Guerra MD, MBA

Forceful vomiting

50% have GERD

Severe chest/epigastric pain

Other sxs depending on time

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

Physical

Subcutaneous emphysema (60%)

Mackler triad (vomiting, CP, SubQ emphysema)

Tachycardia/tachypnea

Hamman sign (crunching sound over heart)

Decreased breath sounds

Esophageal Rupture EMS Treatment O2 IV fluids Pain meds Check lactate (May appear septic) Wayne Guerra MD, MBA

EMS Treatment

O2

IV fluids

Pain meds

Check lactate (May appear septic)

Tension Pneumothorax One way valve Pathophysiology Wayne Guerra MD, MBA

One way valve

Pathophysiology

Tension Pneumothorax Sudden CP & SOB Tachys Hypos  breath sounds Tracheal deviation JVD Sub-Q emphysema Wayne Guerra MD, MBA

Sudden CP & SOB

Tachys

Hypos

 breath sounds

Tracheal deviation

JVD

Sub-Q emphysema

Tension Pneumothorax EMS Treatment O2 Needle thoracostomy IVFs +/- intubation Wayne Guerra MD, MBA

O2

Needle thoracostomy

IVFs

+/- intubation

Needle Thoracostomy Iodine prep 14/16 Ga catheter, 4.5cm minimum Just superior 3 rd rib 1-2 cm from sternum Listen for hissing sound Flutter valve or stopcock Wayne Guerra MD, MBA

Iodine prep

14/16 Ga catheter, 4.5cm minimum

Just superior 3 rd rib 1-2 cm from sternum

Listen for hissing sound

Flutter valve or stopcock

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

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%

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

Coronary artery spasm

Typically occurs at rest

2/3rds have CAD

Spasm can be induced during angiogram

Rx with nitrates and Ca channel blockers

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

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

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

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

Wayne Guerra MD, MBA