Chest Pain: EMS Review

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Chest pain and implications for EMS. Review the history, physical and treatment of chest pain. Learn the most important causes of chest pain in the EMS setting and see great EKG examples of MI and the EKG mimics of cardiac ischemia.

Published in: Health & Medicine

Chest Pain: EMS Review

  1. 1. Chest Pain EMS Implications Wayne Guerra MD, MBA Porter/Littleton/Parker Adventist EMS Pain is inevitable; suffering is optional.
  2. 2. Before I refuse to take your questions, I have an opening statement. Ronald Reagan Wayne Guerra MD, MBA
  3. 3. Objectives <ul><li>Improve EMS History and Physical </li></ul><ul><li>Expand and Focus Differential Diagnosis </li></ul><ul><li>Review EMS Treatment </li></ul><ul><li>Avoid Pitfalls </li></ul><ul><li>Learn A Zebra or Two </li></ul>Experience is something you don't get until just after you need it. Wayne Guerra MD, MBA
  4. 4. 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
  5. 5. To EMS or Not EMS? <ul><li>Private transport: 35 minutes </li></ul><ul><li>EMS: 39 minutes </li></ul><ul><li>Definitely EMS </li></ul>http://heartdisease.about.com/cs/heartattacks/a/chestpainEMS.htm Wayne Guerra MD, MBA
  6. 6. www.iTriageHealth.com Wayne Guerra MD, MBA Differential Diagnosis of Chest Pain is Vast
  7. 7. Possible Causes <ul><li>ACS </li></ul><ul><ul><li>MI </li></ul></ul><ul><ul><li>Unstable Angina </li></ul></ul><ul><li>PE </li></ul><ul><li>Aortic Dissection </li></ul><ul><li>Esophageal Rupture </li></ul><ul><li>Tension Pneumothorax </li></ul>Wayne Guerra MD, MBA
  8. 8. History <ul><li>Establishing Prevalence </li></ul><ul><li>Who, What, Where, How, Why </li></ul><ul><li>Chest pain </li></ul><ul><ul><li>Typical </li></ul></ul><ul><ul><li>Atypical (One study of 430,000 33% had no CP!) </li></ul></ul>JAMA. 283(24):3223–3229, 2000 Wayne Guerra MD, MBA
  9. 9. “ Atypical” Chest Pain <ul><li>Females </li></ul><ul><li>Diabetics </li></ul><ul><li>Elderly </li></ul><ul><ul><li>14% in < 65 years </li></ul></ul><ul><ul><li>21 % in 65-74 years </li></ul></ul><ul><ul><li>32% in >= 75 years </li></ul></ul>Circulation, III: e435-e437, 2005 Wayne Guerra MD, MBA
  10. 10. “ Atypical” Chest Pain <ul><li>23% burning (indigestion) </li></ul><ul><li>5% as sharp and stabbing </li></ul><ul><li>6-9% as positional or pleuritic </li></ul><ul><li>26% SOB </li></ul>Arch Intern Med. 145: 65-69, 1985. Wayne Guerra MD, MBA
  11. 11. “ Atypical” Chest Pain <ul><li>Back, shoulder, neck </li></ul><ul><li>Abdomen </li></ul><ul><li>N/V </li></ul>Wayne Guerra MD, MBA
  12. 12. “ Atypical” Chest Pain <ul><li>Diaphoresis </li></ul><ul><li>Syncope </li></ul><ul><li>Palpitations </li></ul><ul><li>“ Weakness” </li></ul><ul><li>“ Falls” </li></ul>Wayne Guerra MD, MBA
  13. 13. History <ul><li>Past Medical History </li></ul><ul><li>Medications (Bring all into ED) </li></ul>Wayne Guerra MD, MBA
  14. 14. History <ul><li>Past Surgical History </li></ul><ul><li>Recruit others for information </li></ul><ul><li>Recent illnesses </li></ul><ul><li>Social history </li></ul>Wayne Guerra MD, MBA
  15. 15. Physical <ul><li>Vitals are vital </li></ul><ul><li>Heart </li></ul><ul><li>Lungs </li></ul><ul><li>Pulses </li></ul><ul><li>Abdomen </li></ul><ul><li>Neuro </li></ul>http://bit.ly/2o0U2N Wayne Guerra MD, MBA
  16. 16. BP Discrepancy http://bit.ly/hkAZE Wayne Guerra MD, MBA
  17. 17. Diagnostics Wayne Guerra MD, MBA
  18. 18. EKG Get One You Can Read! Wayne Guerra MD, MBA
  19. 19. Stratergery For A Good Tracing <ul><li>Do before transport </li></ul><ul><li>Give pain medications if possible </li></ul><ul><li>Encourage patient to relax </li></ul><ul><li>Ensure good lead contact </li></ul>Wayne Guerra MD, MBA
  20. 20. Importance of CVD an ACS <ul><li>Second most common complaint in ED </li></ul><ul><li>2-5% ACS missed </li></ul>http://bit.ly/hkAZE Wayne Guerra MD, MBA
  21. 21. EKG Mimics of MI <ul><li>Left Ventricular Hypertrophy </li></ul><ul><li>Early Repolarization </li></ul><ul><li>Acute Pericarditis </li></ul><ul><li>Left Ventricular Aneurysm </li></ul>Wayne Guerra MD, MBA
  22. 22. LVH With Strain <ul><li>ST elevation and depression </li></ul><ul><li>T wave changes </li></ul>Wayne Guerra MD, MBA
  23. 23. Early Repolarization Wayne Guerra MD, MBA
  24. 24. Acute Pericarditis PR depression ST Elevation Wayne Guerra MD, MBA
  25. 25. LV Aneurysm Wayne Guerra MD, MBA
  26. 26. 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
  27. 27. 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
  28. 28. Acute Anterior MI Wayne Guerra MD, MBA
  29. 29. Acute Ant-Lat MI Wayne Guerra MD, MBA
  30. 30. Acute Inferior MI Wayne Guerra MD, MBA
  31. 31. Acute Posterior MI http://bit.ly/2Klwk2 Wayne Guerra MD, MBA
  32. 32. Acute Right Ventricular MI Wayne Guerra MD, MBA
  33. 33. Cardiac Alert Wayne Guerra MD, MBA
  34. 34. Acute MI and LBBB <ul><li>ST-segment elevation measuring 1 mm in the same direction with the </li></ul><ul><li>QRS in any lead. </li></ul><ul><li>2) ST-segment depression measuring 1 mm in any of the V 1 through V 3 </li></ul><ul><li>leads. </li></ul>http://bit.ly/2g9EcZ Wayne Guerra MD, MBA
  35. 35. Unstable angina <ul><li>Includes non-Q wave MI </li></ul><ul><li>New pattern of angina </li></ul><ul><li>Angina at rest </li></ul><ul><li>30 day death rate: 3.5% </li></ul><ul><li>30 day MI rate: 8.5% </li></ul>http://bit.ly/PlrtS Wayne Guerra MD, MBA
  36. 36. Pulmonary Embolus <ul><li>650,000 cases annually </li></ul><ul><li>3 rd most common cause of death </li></ul><ul><li>1 st or 2 nd most common unexpected death </li></ul><ul><li>10% die within 60 minutes </li></ul>Wayne Guerra MD, MBA
  37. 37. Pulmonary Embolus Increased Risk <ul><li>Virchow’s Triad </li></ul><ul><ul><li>Venous stasis </li></ul></ul><ul><ul><li>Hypercoagulability </li></ul></ul><ul><ul><li>Inflammation </li></ul></ul>Wayne Guerra MD, MBA
  38. 38. Pulmonary Embolus <ul><li>Pleuritic CP: 74% </li></ul><ul><li>Risk factors: </li></ul><ul><ul><li>Pregnancy and post partum </li></ul></ul><ul><ul><li>BCPs </li></ul></ul><ul><ul><li>Malignancy </li></ul></ul><ul><ul><li>Surgery </li></ul></ul><ul><ul><li>Immoblization </li></ul></ul><ul><ul><li>Inherited hypercoagulability </li></ul></ul>Wayne Guerra MD, MBA
  39. 39. Pulmonary Embolus <ul><li>Signs </li></ul><ul><ul><li>Tachypnea (>16) 92% </li></ul></ul><ul><ul><li>Rales 58% </li></ul></ul><ul><ul><li>Tachycardia (>100) 44% </li></ul></ul><ul><ul><li>Fever (>100 ⁰F) 43% </li></ul></ul><ul><ul><li>Diaphoresis 36% </li></ul></ul><ul><ul><li>Signs of DVT 32% </li></ul></ul>Wayne Guerra MD, MBA
  40. 40. S1Q3T3 Wayne Guerra MD, MBA
  41. 41. Aortic Dissection <ul><li>Characteristic description </li></ul><ul><li>Increased risk </li></ul><ul><li>BP differential </li></ul><ul><li>Murmur </li></ul><ul><li>Can be associated with acute MI </li></ul>Wayne Guerra MD, MBA
  42. 42. Aortic Dissection <ul><li>EMS treatment </li></ul><ul><li>ED treatment </li></ul><ul><li>Hospital treatment </li></ul>Wayne Guerra MD, MBA
  43. 43. Esophageal Rupture <ul><li>Baron von Wassenaer </li></ul><ul><li>Boerhaave’s syndrome (Spontaneous) </li></ul><ul><li>Most are iatrogenic </li></ul>Wayne Guerra MD, MBA
  44. 44. Esophageal Rupture <ul><li>Forceful vomiting </li></ul><ul><li>50% have GERD </li></ul><ul><li>Severe chest/epigastric pain </li></ul><ul><li>Other sxs depending on time </li></ul>Wayne Guerra MD, MBA
  45. 45. Esophageal Rupture <ul><li>Physical </li></ul><ul><ul><li>Subcutaneous emphysema (60%) </li></ul></ul><ul><ul><li>Mackler triad (vomiting, CP, SubQ emphysema) </li></ul></ul><ul><ul><li>Tachycardia/tachypnea </li></ul></ul><ul><ul><li>Hamman sign (crunching sound over heart) </li></ul></ul><ul><ul><li>Decreased breath sounds </li></ul></ul>Wayne Guerra MD, MBA
  46. 46. Esophageal Rupture <ul><li>EMS Treatment </li></ul><ul><ul><li>O2 </li></ul></ul><ul><ul><li>IV fluids </li></ul></ul><ul><ul><li>Pain meds </li></ul></ul><ul><ul><li>Check lactate (May appear septic) </li></ul></ul>Wayne Guerra MD, MBA
  47. 47. Tension Pneumothorax <ul><li>One way valve </li></ul><ul><li>Pathophysiology </li></ul>Wayne Guerra MD, MBA
  48. 48. Tension Pneumothorax <ul><li>Sudden CP & SOB </li></ul><ul><li>Tachys </li></ul><ul><li>Hypos </li></ul><ul><li> breath sounds </li></ul><ul><li>Tracheal deviation </li></ul><ul><li>JVD </li></ul><ul><li>Sub-Q emphysema </li></ul>Wayne Guerra MD, MBA
  49. 49. Tension Pneumothorax EMS Treatment <ul><li>O2 </li></ul><ul><li>Needle thoracostomy </li></ul><ul><li>IVFs </li></ul><ul><li>+/- intubation </li></ul>Wayne Guerra MD, MBA
  50. 50. Needle Thoracostomy <ul><li>Iodine prep </li></ul><ul><li>14/16 Ga catheter, 4.5cm minimum </li></ul><ul><li>Just superior 3 rd rib 1-2 cm from sternum </li></ul><ul><li>Listen for hissing sound </li></ul><ul><li>Flutter valve or stopcock </li></ul>Wayne Guerra MD, MBA
  51. 51. Wayne Guerra MD, MBA
  52. 52. Case 1 <ul><li>32 yo female with crushing cp, sob and diaphoresis </li></ul><ul><li>Meds/PMH/Soc Hx/Past Surg Hx all negative </li></ul><ul><li>120/70, 90, 18, RA Sat=97% </li></ul>Wayne Guerra MD, MBA
  53. 53. Case 1 Wayne Guerra MD, MBA
  54. 54. Case 1: EKG After 1 NTG Diagnosis? Wayne Guerra MD, MBA
  55. 55. Prinzmetal's Angina <ul><li>Coronary artery spasm </li></ul><ul><li>Typically occurs at rest </li></ul><ul><li>2/3rds have CAD </li></ul><ul><li>Spasm can be induced during angiogram </li></ul><ul><li>Rx with nitrates and Ca channel blockers </li></ul>Wayne Guerra MD, MBA
  56. 56. Case 2 <ul><li>50 yo male pressure like chest pain </li></ul><ul><li>PMH: DM, Htn, Elevated cholesterol </li></ul><ul><li>Meds: Insulin, HCTZ, Tenormin, Lipitor </li></ul><ul><li>130/70, 70, 18, RA Sat=96% </li></ul><ul><li>Exam: nl </li></ul>Wayne Guerra MD, MBA
  57. 57. EKG with CP Wayne Guerra MD, MBA
  58. 58. Pain Free After 1 NTG Diagnosis? Wayne Guerra MD, MBA
  59. 59. Wellens Syndrome <ul><li>Isoelectric or minimally  ST followed by concave or straight ST and a symmetrically inverted T wave </li></ul><ul><li>Most common V2-V3, and V4-V6 </li></ul><ul><li>Highly suggestive critical LAD stenosis </li></ul>http://bit.ly/15RAYb Wayne Guerra MD, MBA
  60. 60. Wayne Guerra MD, MBA

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