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Assess & Manage Cardiac Emergencies
- 1. Cardiac Emergencies Focused History, Physical Examination and Management of the Cardiac Patient
- 2. Competency & Policy • Competency AHA/SHA BLS, CMC 03; 13; 14; 18; 19; 22; 23 • JHAH MSP RAC OM 1
- 3. Objectives To provide staff working in remote area clinics with an overview and guidelines for assessing and managing patients with chest pain.
- 4. Introduction Chest pain is cardiac until otherwise determined History is key Physical examination Diagnostic tools Acute coronary syndrome Efficient care = quick recognition Focused history Physical examination
- 5. Focused History Orderly and standard Deductive (patient denial) Observe clinical signs History of present illness OPQRST & SAMPLE Potential causes Listen and note distress Do not diagnose but differentiate Physical examination in parallel with interview Consider masking factors
- 6. OPQRST & ILDCF Onset How did the symptoms begin? Provocation What were you doing? Quality Describe the pain Region/radiation Where is the pain? Severity 0 – 5 (Wong Baker or FRACC) Time/history How long and how frequent? Intensity, location, duration, characteristics and frequency
- 7. SAMPLE Signs and symptoms? Pain, pressure, tightness, squeezing, heartburn, palpitations, radiating pain, shortness of breath, nausea, vomiting, dizziness, lightheadedness, anxiety, weakness, diaphoresis, numbness, tingling, peripheral oedema Alergies? Medications? OTC, herbal, homeopathic, recreational Past history? Family or personal. Cardiac, pacemaker, CABG, stents, respiratory problems, last doctors visit and why Last oral intake? Exacerbation? Exercise? What were you doing?
- 8. Physical Examination Mental status ABCs Skin colour and temp Abnormal pulse Focus on cardiovascular and respiratory systems Assess head-to-toe JVD Lung sounds, heart sounds, palpate chest and abdomen Reassess respiration, rate and pattern
- 9. Listen Heart Sounds, Apex Normal S1, S2 S3 S4
- 10. Look & Feel Surgical scars Pacemakers, cardiac scars, abnormal surgery Transdermal patches Distension Ascites, dependent oedema Pain Tenderness Location Oedema
- 11. Assessment Diagnostic Tools CC, PMH and 1o symptoms EGC (within 10 mins) SpO2 Capnography Baseline and serial vital signs Postural hypotension Blood tests Troponin, serial CK-MB, U&Es
- 12. Subjective Assessment Possible causes: Aortic dissection, pneumothroax, PE, pleurisy, infection, oesophageal varices, CA, pericarditis, musculoskeletal, indigestion, … Focus on OPQRST and abnormal findings Classic pain Heavy or squeezing and radiating >20 mins may include Diaphoresis Nausea & vomitting Anxiety No positional comfort Levine’s sign
- 13. Positional pain suggests Pleurisy, pericarditis, pneumonia, musculoskeletal Tearing pain suggests Aneurism Silent MI Elderly, diabetic, female, neuropathic co-morbid conditions Atypical symptoms include Syncope, altered mental status, weakness, fatigue, dyspnoea, epigastric pain, back pain, right side radiating pain Subjective Assessment
- 14. Elderly or diabetic patients SoB indicative of MI Exertional/paroxysmal nocturnal dyspnoea Strong indication of MI Chronic heart failure, acute COPD SoB Pink sputum JVD Peripheral oedema Chest discomfort Inspiratory rales Diuretic medications Recent medication changes Subjective Assessment
- 15. Syncope Elderly may only present with CC of syncope Cardiac causes Heart blocks Dysrythmias Aortic stenosis Unstable angina Non-cardiac causes Postural hypotension Medications Vasovagal reaction Vasodepressor syncope
- 16. Syncope Assessment Where were you? What were you doing? Any pain or palpitations? Dyspnoea? Dizziness? Weakness Similar events? How long were you out?
- 17. Management Assessment SAMPLE OPQRST (ILDCF) Vital signs including apical and peripheral pulse ESI triage MONA protocol Asprin 300 -325 mg (chewed) O2 via NRB Nitroglycerine 0.4-0.8 mg, every 5 mins, max 3 doses if SBP > 90 mmHg IV cannulation, 18G ACF with 0.9% saline at 50 mLs/hr
- 18. Ongoing Management Clinic level dependent Physician clinics: Morphine Thrombolysis IV nitroglycerin Troponin, CK-MB ECG Serial vital signs Transfer and notify Nurse clinics: ECG Serial vital signs Consult Transfer and notify
- 19. Ongoing Management Door to ECG in under 10 mins (KPI) Door to needle in under 30 mins Comprehensive documentation Pain relief Dysrhythmias and their resolution Respiratory distress or lack of Anxiety or diminishing anxiety level
- 20. Summary Standard approach Recognise Focus history and physical examination Understand different etiologies Formulate a working hypothesis Focused history, OPQRST and SAMPLE Clinical signs, symptoms and subtlety Stabilise and transfer
- 21. References Elling, B., Elling, K. (2003). Principles of Patient Assessment in EMS. [Online]. Available at: http://www.delmarlearning.com/companions/content/0766838994/ppt/index.asp?isbn=0766838994. [Accessed on: 18 Jult 2015] RAC OM 1 Att H
Editor's Notes
- Describe the most common cardiovascular chief complaints found in the prehospital setting. Describe why the patient’s history is so important when making a field impression of acute coronary syndrome (ACS). List several ways to ask a patient if he is experiencing chest pain. List several causes of chest pain that are not cardiac related Explain why “rule out” is no longer an acceptable term for the EMS provider when making a field impression of a patient. Using OPQRST describe specific information pertaining to the FH of the patient with a CC or chest pain. Using SAMPLE describe specific information pertaining to the FH of the patient with a CC of chest pain. Describe the significance of JVD in a patient with chest pain. Describe possible abnormal lung sounds that may be detected in a patient with chest pain or dyspnea. Describe the normal heart sounds S1 and S2. Describe the abnormal heart sounds S3 and S4. Describe the location of the PMI and its significance. List abnormal features found on the chest of a patient with a cardiac history. Describe the locations on the body that the EMS provider may appreciate dependent edema. List the diagnostic tools the EMS provider may use to assess the patient with a possible ACS. List medications that may cause a syncopal event. Describe the possible findings associated with a silent MI. Describe why dyspnea is a very common symptom associated with MI. List the causes of non-cardiac syncope.
- Suspicion of an acute coronary syndrome is primarily based on the patient’s history. The PE and use of diagnostic tools are necessary, but a complete history is the most helpful in diagnosing a cardiac problem. The EMS provider treating a patient with ACS needs to work fast and efficiently. Efficiency depends on the EMS provider’s ability to obtain a FH & PE in an effort to recognize less vague conditions such as pneumonia, pleurisy or anxiety reactions.
- The FH is a key step in formulating a rational course of treatment. The approach must be orderly to avoid missing important information, possibly leading to less successful outcomes. Interviewing is a tool the EMS provider needs to develop: Be deductive and learn to ask the same question in a variety of ways A patient may deny chest pain but will admit having pressure or discomfort While collecting info, give careful consideration to the obvious symptoms, clinical signs, as well as subtle cues, found in the FH Obtain the history of the present illness (HPI) by using the acronym OPQRST, as well as the SAMPLE history. Formulate a field impression (working diagnosis) of the patient’s condition by considering the list of potential causes of the chest pain. Listen carefully to the patient and note the level of distress. The EMS provider does not do a specific ACS, rather he begins to differentiate the info obtained. In most cases the patient interview is conducted simultaneously with the PE. Consider that pain anywhere from the navel to the jaw is cardiac ischemia until proven otherwise. Not all patients have “substernal” chest pain when experiencing ACS (i.e.: women, elderly, and diabetics). They may complain of feeling weak, have mild dyspnea or “just do not feel right” when experiencing an ACS.
- O – How did the symptom begin? P – What was the patient doing at the time of onset? Q – Have the patient describe the type of pain in his own words. R – Ask the patient to point to the location of the pain. S – Compare to a similar experience or on a scale of 1 to 10. T – How long has the symptom been present?
- S – symptoms associated with ACS may include: Chest pain, pressure, tightness, squeezing, heartburn, palpations Radiating pain to stomach, arm, neck, jaw, or back Shortness of breath Indigestion, nausea, vomiting, dizziness, lightheaded Anxiety, a feeling that something is wrong Weakness, fatigue, AMS, near fainting or syncope Sweating (diaphoresis) Tingling or numbness Swelling of the feet, legs, hands (peripheral edema) A – do you have any allergies to med? M – do you take any prescribed, OTC, homeopathic, herbal, of recreational drugs? P – ask about pertinent PMH like: heart condition, pacemaker, CABG, stent, breathing problems, last Dr. visit, etc? L – what was you last oral intake? E – any exertional or non-exertional events leading up to symptoms?
- Assess mental status Suspect cardiac related conditions if any of the following are discovered during the IA: AMS – may indicate decreased perfusion due to poor cardiac output Skin CTC – pale or diaphoretic due to shock ABCs – dyspnea, abnormal breathing patterns, or adventitious breath sounds Abnormal distal pulses: weak or absent, unequal, irregular, tachycardia, or bradycardia Focus on the cardiovascular and respiratory systems. Assess head-to-toe Look at the neck to assess for presence of JVD (45 degree angle) Listen to lung sounds, heart sounds, inspect and palpate the chest and abdomen Reassess the respiratory rate and breathing pattern
- Listen to heart sounds The normal sounds are S-1 and S-2 or the “lub-dub” sound S-1 is the first sound and is produced by the AV valves during ventricular contraction S-2 is the second sound and is produced during ventricular diastole Abnormal sounds are extra sounds (ie: S-3, S-4, murmurs, gallops and clicks) To listen for heart sounds place the bell of the stethoscope lightly over the point of maximal impulse (PMI) on the left anterior chest at the 5th intercostal space and the midclavicular line
- Visually inspect and palpate the chest and abdomen noting the presence of: Surgical scars (ie: pacemakers, defibrillators, cardiac and abnormal surgeries) Transdermal patches Distension from bloating, ascites or dependent edema Pain reproducible with movement or not Tenderness, masses, and pulsations Location of the PMI Peripheral edema
- Primary components are utilized with diagnosis of an MI: Medical history including CC or primary symptom ECG analysis Cardiac enzyme analysis An ECG abnormality alone does not diagnose or exclude an AMI, but can be helpful to guide treatment. When an MI is occurring a 12 lead ECG may help to identify the location of ischemia or infarct. Additional diagnostic tools include: Pulse oximetry Capnography Baseline & serial VS Orthostatic changes Blood test Troponin, myosin, CK-MB over 12-24 hours
- Can be caused by many disease processes, as well as ACS: Aortic dissection, oesophageal varicies, PE, pneumothroax, pleurisy, infection To help determine origin of chest pain focus on the following key points: Onset Duration Precise quality of pain Radiation Associated findings Classic pain from AMI is often described as “heaviness or squeezing” or a sudden painful sensation of pressure. May radiate to arms, shoulders, neck or back and usually last more than 20 minutes Associated signs/symptoms may include: Sweating Nausea/vomiting Anxiety No position of comfort Levine’s sign Chest pain that changes intensity with positioning or breathing may be associated with pleurisy, pneumothorax, pericarditis, pneumonia, or musculoskeletal problems. Any condition that causes inflammation of the lungs or heart can extend to the pleural surfaces of the lung and produce chest pain. This is called pleuritic pain. Associated signs for pleuritic pain include: infection, elevated temperature, chills, increased sputum or coughing. Patients with limited mobility are at increased risk for aspiration, pneumonia, and respiratory infection. Pain described as a “tearing” sensation in the chest or abdomen or back is suggestive of an AAA. The “silent MI” is a significant number of patients who do not have typical MI symptoms. The elderly, women, diabetics, or patients with neuropathic conditions experience MI with atypical and subtle symptoms Atypical symptoms include: AMS or syncope Weakness or fatigue Dyspnea – mild to severe exertional Epigastric, back or neck pain Shortness of breath especially in the elderly or diabetic may be the primary or only symptom of AMI or acute heart failure Shortness of breath, exertional dyspnea, and paroxysmal nocturnal dyspnea (PND) strongly suggests a cardiac problem CHF and acute exacerbation of COPD are often difficult to differentiate. Look for a history of heart failure and any of the following: SOB with or without pink tinged sputum Presence of JVD Peripheral edema Chest discomfort Cardiac dysrhythmias Inspiratory rales/crackles in the lungs Diuretic medications or recent medication changes
- Chest pain that changes intensity with positioning or breathing may be associated with pleurisy, pneumothorax, pericarditis, pneumonia, or musculoskeletal problems. Any condition that causes inflammation of the lungs or heart can extend to the pleural surfaces of the lung and produce chest pain. This is called pleuritic pain. Associated signs for pleuritic pain include: infection, elevated temperature, chills, increased sputum or coughing. Patients with limited mobility are at increased risk for aspiration, pneumonia, and respiratory infection. Pain described as a “tearing” sensation in the chest or abdomen or back is suggestive of an AAA. The “silent MI” is a significant number of patients who do not have typical MI symptoms. The elderly, women, diabetics, or patients with neuropathic conditions experience MI with atypical and subtle symptoms Atypical symptoms include: AMS or syncope Weakness or fatigue Dyspnea – mild to severe exertional Epigastric, back or neck pain
- Shortness of breath especially in the elderly or diabetic may be the primary or only symptom of AMI or acute heart failure Shortness of breath, exertional dyspnea, and paroxysmal nocturnal dyspnea (PND) strongly suggests a cardiac problem CHF and acute exacerbation of COPD are often difficult to differentiate. Look for a history of heart failure and any of the following: SOB with or without pink tinged sputum Presence of JVD Peripheral edema Chest discomfort Cardiac dysrhythmias Inspiratory rales/crackles in the lungs Diuretic medications or recent medication changes
- Temporary loss of consciousness due to fall in BP In the elderly may be the only clinical sign of a cardiac problem. Cardiac causes of syncope include: Heart blocks Dysrhythmias (bradycardia, blocks, SVTs, Stokes-Adams Syndrome, Sick Sinus Syndrome) Aortic stenosis, AMI, and angina Non-Cardiac causes of syncope include: Orthostatic or postural hypotension Medications Vasovagal faint Vasodepressor syncope
- Ask about pre and post syncope information such as: Position of the patient Chest pain or palpitations Dyspnea Dizzyness or weakness Any similar events Duration of loss of consciousness (LOC) Duration of LOC is a helpful clue: Cardiac and neurologic syncope usually occur without warning. Recovery is often slow with confusion, headache, dizziness, orthostatic changes or local dysfunction Non-Cardiac syncope often occurs in patients without a PMH. Usually caused by a stressor such as pain, emotion or medication and last briefly with a quick recovery period
- Initial Assessment • Skin color: Pale, cool and clammy • Respiratory effort: Dyspnea • Anxiety/Circulation: Palpitations B. Signs and Symptoms - SAMPLE S. Signs and Symptoms (Nausea, vomiting, SOB, Diaphoresis, Cough, Fever, Dizziness, Palpitations). A. Allergies (Does the patient have any allergies?). M. Medication (Does the patient currently take any medication? Document?). P. Past medical history (Does the patient have any medical condition or relevant medical history). L. Last oral intake (What time did the patient last eat and drink?). E. Events leading up to (what happened/what where you doing when the pain started?). C. Pain Assessment – OPQRST. O. Onset (What was the patient doing when the pain started? Gradual? Sudden?). P. Provoking Factors (Is there anything the patient would normally do to make the pain better/worse.). Q. Quality (Ask the patient to describe the pain/symptoms/discomfort they are experiencing? Is it steady? Does the pain come and go?). R. Region/Radiate (Ask the patient to point with one finger where they feel the pain/discomfort at its worst? Does the pain move or radiate anywhere else in the body?). S. Severity (pain scale 0-5 when the pain first started and how?). T. Time (As the patient when the pain began? Is this the first time you had pain like this?). D. Objective assessment 1) Complete vital signs (including apical and peripheral pulse and breath sounds). 2) Presence or absence of edema: Pitting or Dependent. 3) Presence or absence of neck vein distention. Assess the patient while obtaining their medical history. Obtain pain score. B. Classify as per triage guidelines. If the chest pain is cardiac in origin, or epigastric, take the patient to the treatment area immediately. C. If indicated for the patient, the nurse must implement the chest pain protocol. This should include: 1) For all patients use minimum 10L/min O2 via non re-breathing mask; consider lower flow rate for patients which chronic obstructive pulmonary disease i.e., 2 L/min O2 via nasal prongs. 2) ASA 325 mg PO tablet (Prior to giving ASA consider contraindications i.e., ask if patient has known allergy to ASA and/or history of Upper GI bleeding). 3) Nitroglycerin 0.4 mg sublingual if patient is systolic BP greater than 90. Repeat x 3 at 5 minute intervals if patients’ pain score is above zero and BP greater than 90. If pain is not relieved by Nitroglycerin or if Nitroglycerin is contraindicated (i.e., BP less than 90), and when Morphine Sulphate is not available consider using Entonox/Nitronox for pain relief. Titrate analgesia according to patient’s pain score/blood pressure. 4) Establish a peripheral IV line, with Normal Saline at TKO. In the absence of heart failure and the BP is low consider fluid bolus.
- 5) In Physician level, 1 and 2 operated facilities draw lab works (CBC, Chemistry and Troponin I). 6) In Physician operated facilities and where medications are available prepare to administer following medications as per clinicians orders : a. Morphine Sulphate 1 to 5 mg IV every 5 to 30 minutes, as needed, for patients whose symptoms are not relieved after three serial sublingual nitroglycerin tablets or whose symptoms reoccur b. Have Narcan on stand-by for overdose of opiate (morphine) if needed in an initial dose of 0.4 to 2 mg IV, the dose may be repeated at 2 to 3 minute intervals if needed c. In all cases: Titrate analgesia according to patient’s pain score/blood pressure/respiratory rate/level of consciousness d. Thrombolytic Medications – see MSP-180 Thrombolytic Therapy e. Nitroglycerin f. Retaplase D. Obtain 12 lead EKG STAT and pass (or fax it) to the clinician immediately. Note: If EKG shows inferior MI – obtain right-sided EKG. Attach to cardiac monitoring and take strip. Forward to Dhahran EMS for evaluation as required. F. Take serial vital signs and pain score and reassess for pain relief post analgesia, minimum of every 5 minutes. G. Chest x-ray can be done at receiving hospital. H. Facilitate rapid admission/transfer in the shortest time possible. Arrange Medevac as necessary. Notify receiving hospital of expected time of arrival and current patient status, updating as necessary. Note: With the management of MI’s it is crucial to remember that positive outcomes are linked to Time i.e., “Door to EKG time” – usually 5-10 minutes; and Door to Needle Time” (Retaplase) – 30 minutes. Document initial assessment data, EMS interventions, and patient’s response to all treatments. B. Relief of pain. C. Resolution of Dysrhythmias. D. Absence of respiratory distress. E. Diminished anxiety
- Note: With the management of MI’s it is crucial to remember that positive outcomes are linked to Time i.e., “Door to EKG time” – usually 5-10 minutes; and Door to Needle Time” (Retaplase) – 30 minutes. Document initial assessment data, EMS interventions, and patient’s response to all treatments. B. Relief of pain. C. Resolution of Dysrhythmias. D. Absence of respiratory distress. E. Diminished anxiety
- Utilize the standardized approach to assess the patient with cardiac problems. Recognize cardiac related symptoms, obtain a FH and perform an appropriate PE. Many etiologies of chest pain are difficult to differentiate. The Hx is the most important factor in making a field impression of ACS. Formulate a field impression from the FH, OPQRST and SAMPLE. Be alert for subtle clues, as well as obvious clinical signs & symptoms.