Understanding Chest Pain

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Understanding Chest Pain

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Understanding Chest Pain
• Chest Pain is a broad and purposefully
vague term; where do we consider the
chest? Solely the front of the
body? Under the arms? Between the
shoulder blades?
• Pain from the chest can present anywhere
in the upper torso and, furthermore,
can radiate(spread) or refer (be felt
elsewhere) in different places.

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Understanding Chest Pain
• And how does the casualty describe the
pain? A vice-like crushing pain? A dull,
nagging ache or a sharp, focused stabbing
pain? Is it constant or does it come and
go? Is it continual or is it brought on by
exercise or some other stimulus?
• As well as the wide range of signs or
symptoms which may present, Chest Pain
may indicate as a variety of conditions,
from trivial to life-threatening:

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Cardiovascular
• Angina Pectoris
• Myocardial infarction ("heart attack")
• Dissecting aortic aneurysm
• Heart failure
• Pericarditis and cardiac tamponade
• Arrhythmia - atrial fibrillation and a number
of other arrhythmias can cause chest pain.

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Pulmonary
• Pulmonary embolism
• Pneumonia
• Hemothorax
• Pneumothorax and Tension pneumothorax
• Pleurisy - an inflammation of the pleura
(lining of the chest cavity) which can cause
painful respiration

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Gastro-Intestinal
• Heartburn
• Indigestion
• Hiatus hernia - a protrusion of the upper
part of the stomach into the thorax through
a tear or weakness in the diaphragm.
• Neuromuscular disorders of the
oesophagus

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Chest Wall
• Chest wall injury
• Nerve damage
• Precordial catch syndrome - another
benign and harmless form of a sharp,
localised chest pain often mistaken for
heart disease
• Breast conditions
• Tuberculosis

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Physiological
• Panic attack
• Anxiety
• Clinical depression
• Hypochondria

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Understanding Chest Pain
• While the list of possible conditions may
be intimidating and diagnosis outside of a
hospital my be difficult we shall see that
there are common themes of treatment for
all.

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The Spectrum of Cardiac
Conditions
• Many cardiac conditions are functions of
lifestyle; long term health problems which
lead to atherosclerotic or arteriosclerotic
problems or high blood pressure
(hypertension). The most significant
factors include:
• Smoking
• Alcohol
• Poor diet

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The Spectrum of Cardiac
Conditions
• Lack of exercise / sedentary work or
lifestyle
• High stress
• Age
• Being male
• Family history
• Diabetes or other causative medical
conditions

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The Spectrum of Cardiac
Conditions
• With this in mind, knowing your casualty
will already help you form an opinion of
what the cause of their chest pain might
be; fit young, healthy people tend not to
have cardiac disease!

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The Spectrum of Cardiac
Conditions
• The spectrum of cardiac conditions which
are commonly found include
both acute (severe and sudden onset)
and chronic (long term development)
medical conditions. This article looks at:
• Angina
• Heart Attack
• Heart Failure
• Aortic Aneurysm

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Angina Pectoris
• Chest pain does not always mean a
person is having a heart attack
(myocardial infarction or "MI"). Angina is a
chronic condition and typically a symptom
of atherosclerotic coronary
disease. Narrowing of the coronary
arteries reduce the amount of oxygen the
heart receives.

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Angina Pectoris
• In normal situations or at rest the patient
feels no discomfort as the heart is
receiving enough oxygen to meet it's
normal demand.
• During periods of exercise or stress, when
the heart is working harder, the oxygen
demand increases but is not able to to be
met. It is during these moments that
patients will exhibit chest pain including:

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Angina Pectoris
• Central chest pain
• May radiate across the chest or into the
jaw, left arm or throat
• The pain usually lasts from 3 to 8 minutes
but rarely above 15 minutes1.
• Pain is usually eased with rest (as the
hearts oxygen demand reduces) or
administration of the patient's Glyceryl
Trinitrate medicine.

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Angina Pectoris
• Angina Treatment (2,3)
• 2 puffs of GTN spray under the tongue –
pain should ease within 5 minutes.
• If there is no improvement after 5 minutes,
the casualty should administer a further 2
puffs.
• If there is no improvement after a further 5
minutes, the casualty should administer a
third does of 2 puffs.

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Angina Pectoris
• If there is no improvement after a further 5
minutes (15 minutes in total since first
administration) assume Heart Attack.
• Call 999 and encourage the casualty to
chew 300mg aspirin.
• Resting the patient and positioning them
seated, or sat on the floor against a wall,
together with prompt medication usually
eases the condition. This is Stable
Angina.

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Angina Pectoris
• Unstable Angina is characterised by the
signs and symptoms above but is
triggered by progressively less exercise or
fewer stimuli. If untreated, Unstable
Angina can lead to an MI.
• If in doubt - ASSUME IT IS A HEART
ATTACK

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Heart Attack
• Where angina is caused by a restriction of
the cardiac vessels, a heart attack (MI) is
usually caused by a complete or partial
blockage; typically a piece
of atherosclerotic plaque that has
detached from the vessel wall during a
moment of stress or exercise and become
lodged within a cardiac artery.

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Heart Attack
• Alternatively, the build up of plaque can be
so great the long term ischemia causes
irreparable damage to the affected part of
the heart.
• In either situation, the lack of oxygen
causes death of the muscle tissue which
interrupts the normal electrical activity of
the heart, resulting in Cardiac Arrest.

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Heart Attack
• Cardiac Arrest is a medical emergency
where death is imminent if decisive action
is not taken quickly. Time is the most
critical factor in a successful
resuscitation. The casualty needs rapid
defibrillation with CPR provided in the
mean time to maintain oxygen supply to
the brain. If defibrillation is not available,
death is inevitable.

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Heart Attack
• When unexpected Cardiac Arrest leads to
to death, this is called Sudden Cardiac
Death.

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Signs & Symptoms
• The conscious casualty may present a
number of symptoms; the onset of
symptoms is usually gradual, over several
minutes, and rarely instantaneous.
• Chest pain is the most common symptom
of acute MI and is often described as a
sensation of tightness, pressure, or
squeezing.

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Signs & Symptoms
• Pain radiates most often to the left arm,
but may also radiate to the
lower jaw, neck, right arm, back, or
epigastrium,where it may
mimic heartburn.
• Other symptoms include excessive
sweating (diaphoresis) weakness, light-
headedness, nausea, vomiting and
palpitations.

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Signs & Symptoms
• These symptoms are likely to be induced
by a massive surge
of catecholamines from the sympathetic
nervous systemwhich occurs in response
to pain and the haemodynamic
abnormalities that result from cardiac
dysfunction.
• Due to a lack of oxygen reaching the brain
(inadequate cerebral perfusion)
unconsciousness follows.

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Treatment
• The conscious casualty should be sat
down against something they can rest on;
traditionally anyone exhibiting breathing
problems or chest pain will not want to lie
down.
• Bringing their knees up is said to reduce
strain on the heart and increase perfusion
to a marginal degree.
• If Oxygen is available it should be
administered now.

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Treatment
• If the casualty has their own medication,
they should be assisted to administer it.
• If they do not have their medication they
should chew a 300mg aspirin or place a
soluble aspirin on the tongue - they should
not swallow the aspirin.

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Treatment
• Encouraging the casualty to chew - or
allow the soluble aspirin to dissolve in the
mouth - will allow the aspirin to be
absorbed through the mucous membrane
of the cheeks, allowing the drug to enter
the blood stream much quicker than if it
were swallowed.

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Treatment
• If a defibrillator is available, rapid
defibrillation takes priority over attempted
CPR. The defibrillator pads should be
applied to the casualty as soon as
possible and the defibrillator activated,
even if the casualty is conscious and
breathing; the defibrillator will be able to
monitor the heart rhythm. There is no
danger in applying a defibrillator to a
conscious person prior to cardiac arrest.

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Treatment
• If the casualty becomes unconscious,
and/or if there is any doubt that their
breathing is not normal the casualty
should be resuscitated in line with current,
national protocols. (4)
• If the airway is compromised or
ventilations are difficult, chest
compressions take priority.

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Treatment
• Remember: Defibrillation takes priority
over CPR if both are available
• Chest compressions take priority over
ventilations if necessary

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Heart Failure
• Heart failure is a typically chronic condition
characterised by reduced cardiac output -
the rate and volume of blood circulated by
the heart. This can be caused by any of
the heart diseases mentioned above but
also by:
• Other heart diseases such as myocarditis
( myo= muscle, card= cardiac, itis=
inflamation)

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Heart Failure
• Hypertension
• Heart valve abnormalities such as leaking
or reverse flow back into the chambers
• Arrhythmias; ineffective heart rhythms
• Cardiac tamponade - a build up of fluid in
the sac surrounding the heart, inhibiting
effective contraction and relaxation of the
heart muscle preventing the ventricles
from filling fully with blood.

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Heart Failure
• When the pumping function of the left
ventricle (which supplies the aorta with
oxygenated blood to the rest of the body)
cannot keep up with the input from the left
atrium (bringing freshly oxygenated blood
from the lungs via the pulmonary veins)
the heart attempts two compensate by two
possible mechanisms:
• Increase in heart rate
• Increase in size of the left ventricle

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Heart Failure
• These compensatory mechanisms are not
sustainable in the long term. Heart failure
may occur in the left ventricle
independently or in both ventricles. Left
ventricular failure, unable to keep up with
the input from the pulmonary veins, forces
blood to back up into the alveoli of the
lungs causingpulmonary oedmea - fluid
leaking into the lungs.

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Heart Failure
• Failure of both ventricles can impair blood
flow leading to reduced systemic perfusion
which may manifest as weakness,
confusion, drowsiness and low blood
pressure (5).

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Signs & Symptoms
• Shortness of breath - typically occurring
when lying and eased by sitting upright.
• Sometimes with a dry cough.
• Fine crackles or wheezing on inhalation
• Frothy, pink sputum
• Distended jugular veins as a result of
increased venous pressure

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Signs & Symptoms
• Swollen ankles may indicate right sided
heart failure
• Pale or cyanosed skin
• Agitation or restlessness
• Fast heart rate and breathing, high blood
pressure

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Treatment
• Encourage the casualty to sit upright
• Assess the patient for signs and
symptoms listed above
• Be reassuring; stress and anxiety of
breathing problems cause a viscious
feedback loop
• Gather a history of the patient - known
medical conditions, medications...

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Treatment
• Encourage the patient to administer their
medication
• Contact the emergency services

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Aortic Aneurism
• An aortic aneurism is a weakening and
subsequent widening of the aorta - the
main artery which leaves the heart to
transport oxygenated blood to the body -
typically caused by uncontrolled high
blood pressure.

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Aortic Aneurism
• A dissecting aneurism occurs when the
inner layers of the aorta become
separated allowing blood, under high
pressure, to leak in between the layers
further increasing the risk of rupture. A
ruptured aorta will lead to almost instant
death due to the vast amounts of
uncontrolled internal bleeding.

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Aortic Aneurism
• An aortic aneurism may be very difficult to
identify in a pre-hospital setting without
equipment and the signs and symptoms
may not initially be easy to differentiate
from an MI but there are a number of
'classic' characteristics which may be
present:

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Aortic Aneurism
• The pain from an MI is often preceded by
other symptoms (see above), becoming
more severe with time and often described
as a 'crushing pressure' rather than
a 'stabbing' pain.
• The sharp, stabbing pain of an aortic
aneurism is usually abrupt and without
additional symptoms and does not abate,
nor is it relived with rest.

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Aortic Aneurism
• Pain is typically felt in the back, between
the shoulder blades. This can occur in an
MI but much more rarely.
• If you have equipment available there may
be a difference in blood pressure on each
arm or it may be difficult to detect a pulse
in the lower limbs compared with the arms.

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Treatment
• Arrange transport to hospital immediatly

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Conclusions
• Chest Pain can mean different things to
different people so to attempt to identify
the causes we need to know what to look
for as the conditions sometimes present
recognisable features that have been
discussed in this powerpoint.