1. Sorting It Out: Chest Pain, Cardiac Arrest and SOB
Michael Lohmeier, MD
June 24, 2014

2. Sorting It All Out… Thank You for this opportunity Before I begin…
A Little About Me…
Michael Lohmeier
Assistant Professor of Medicine, Emergency Med
Medical Director; Madison Fire, FitchRona EMS, Middleton EMS, Dane County EMS, UW PD First Responders
Medical Director, University of Wisconsin EEC
Director, EMS Rotation for Residents

3. Sorting It All Out… Per the Wisconsin EMS Association Website
598,416 calls for EMS in 2011
15% increase from 2010
40% of calls are responded to by 10 services in the state
In 1992, only 9% of Wisconsin ambulance services operated at the Paramedic level
Today, 32% of services are licensed at this level
68% of services are trained and authorized to start IVs and administer 8 or more medications
~20% of calls require the administration of one or more meds
~10% are true “life threatening” situations
That’s 59,000 patients per year!

4. Sorting It All Out… Quotable
“The only man who never makes a mistake is the man who never does anything.”
-Theodore Roosevelt

5. Sorting It All Out… Why should you care?
Chest Pain is one of the most common reasons for activating
Unofficial Dane County Data
Emergency Department data
Not everything that presents with chest pain is cardiac
Time lost is muscle lost
EMS is triaged to cardiac cath labs in many parts of the state
The public expects you to get it right
Misdiagnosing an MI can be deadly!
Aortic dissection
Pericarditis
Dane County Data – Jan 1, 2014 – June 23, 2014 there were 12,389 calls. Chest Pain was 6.4%, Cardiac Arrest was 1.23%, Asthma and COPD was 1.58%
Data is not perfect; 7.18% of calls were for “Other” and 8.59% were for “pain”.
129.8 million ED visits in For the non-traumatic visits, chest pain was #2 and shortness of breath was #6

6. Sorting It All Out…
Chest Pain, Shortness of Breath and Cardiac Arrest can be on a spectrum of cardiac ischemia – or completely unrelated!
Approximately million people visit the ED in 2010
5.4% of visits for chest pain
2.7% of visits for shortness of breath
2.7% of visits for cough
Critical diagnoses causing either varies widely
ACS, aortic dissection, pulmonary embolism, tension pneumothorax, pericardial tamponade, esophageal rupture

7. Sorting It All Out… Differentials Chest Pain Shortness of Breath
Acute MI
Unstable Angina PE
Aortic Dissection
Pneumothorax
Cardiac Tamponade
Esophageal Rupture
Pericarditis
Shortness of Breath
Asthma and COPD
Pneumonia
Pneumothorax
Pulmonary Embolism
Trauma
Acute Coronary Syndrome
Endocrine (DKA, metabolic acidosis)
Hematologic (anemia)
Toxins (Salicylate overdose)
Ascites

8. Sorting It All Out… Differentials Chest Pain Shortness of Breath
Acute MI
Unstable Angina PE
Aortic Dissection
Pneumothorax
Cardiac Tamponade
Esophageal Rupture
Pericarditis
Shortness of Breath
Asthma and COPD
Pneumonia
Pneumothorax
Pulmonary Embolism
Trauma
Acute Coronary Syndrome
Endocrine (DKA, metabolic acidosis)
Hematologic (anemia)
Toxins (Salicylate overdose)
Ascites

9. Sorting It All Out… What causes chest pain?
Afferent nerve fibers carry signals from the body to the brain
Fibers from the heart, lungs, great vessels and esophagus enter the same thoracic dorsal ganglia
These ganglia overlap the 3 segments above and below
Location and quality of the pain are indistinct to the patient
Can be from the jaw to the epigastrium
Some somatic afferent fibers synapse in the same dorsal root ganglia and can “confuse” the CNS
Gives referred pain

10. Sorting It All Out… What causes shortness of breath?
“dyspnea” is the term used for the sensation of breathlessness and the patient’s reaction
Neither the clinical severity nor the patient’s perception correlates well with the seriousness of underlying pathology
The actual mechanisms for dyspnea are unknown
Imbalance between the respiratory center in the medulla oblongata and the chemoreceptors near the carotid bodies
Increased work of breathing
Increased respiratory drive

11. Sorting It All Out… Just to recap…
Chest Pain is indistinct to the patient, source may be unclear on exam
Dyspnea is subjective, may be related to a physical, metabolic or psychiatric condition
Differential is enormous, from non-emergent to the most critical diagnoses in medicine
Awesome.

12. Sorting It All Out…
What are the life threats, and does this patient need an intervention immediately?
There is no simple algorithm
Keep your approach organized and systematic
Keys to narrow down your differential will be in the history, physical exam and EKG in ~90% of patients
Majority of diagnosis is going to come from the history
If they’re already in cardiac arrest, run the ACLS algorithms
Designed to treat the underlying etiologiy of arrest
We want to prevent that from happening!

13. Sorting It All Out… History Don’t forget your O-P-Q-R-S-T! Onset
What were you doing when you started having pain?
Provocation or palliation
What makes the pain better or worse?
Quality
Can you describe the pain? Sharp, dull, achy, stabbing, burning?
Region and Radiation
Where is the pain, and does it go anywhere?
Severity
On a scale of 0-10 with zero being no pain, how bad does this hurt?
Timing
How long has this been going on and how has it changed since the beginning?
Activity at onset may be helpful. Pain with exertion suggests ischemic coronary syndrome, while progressive pain at rest suggests MI. Sudden onset pain may be PE, PTX or aortic dissection. Pain after eating may be a GI source
Pain that worsens with with exertion and improves with rest is more likely related to coronary ischemia. Pain related to meals may be GI related. Pain worse with breathing is more often pulmonary, pericardial and MSK causes
Squeezing, crushing or pressure are more indicative of a cardiac ischemia. Tearing pain may be an aortic dissection. Sharp and stabbing pain is more common in pulmonary and MSK causes. Burning and indigestion may indicate GI source
Pain that is localized to a small area is more likely somatic vs. visceral. Pain in the periphery of the chest more likely pulmonary. Low chest or upper epigastric may be GI or cardiac in nature. Radiation to the back is concerning for dissection, pancreatitis, posterior GI ulcers. Radiation to the arms, neck of jaw more commonly from cardiac cause
Severity of pain should be documented at onset, peak, present and after interventions
Pain that lasts a few seconds or minutes is typically not cardiac in nature. Exertional pain that abates with rest may be cardiac ischemia. Severe, maximum pain at onset is concerning for dissection. Mile pain that lasts over days is less likely to be serious than the fluctuating or stuttering chest pain.

14. Sorting It All Out… History
A history of prior pain and the diagnosis can be quite helpful in narrowing down your differential
But beware – the biggest barrier to making the correct diagnosis is…
The previous diagnosis!!
Associated symptoms may be helpful as well
Diaphoresis should suggest a serious or visceral cause
Hemoptysis is a classic PE sign – that is seen in about 1/5 the time
Nausea and Vomiting can be GI or cardiac in nature
Risk factors are important to consider when evaluating a patient
Good to know from a population basis, not as helpful with the individual

15. Sorting It All Out… Helpful Physical Exam findings Appearance
Acute Respiratory Distress
Diaphoresis
Vital Signs
Hypotension
Tachycardia
Bradycardia
Hypertension
Fever
Hypoxemia
Acute respiratory distress – PE, Tension Pneumo, Acute MI
Diaphoresis – PTX, Acute MI, Aortic Dissection, Coronary Ischemia, PE, Esophageal Rupture, Unstable Angina, Cholecystitis, Perforated Peptic Ulcer
Hypotension – Tension Pneumothorax, PE, Acute MI, Aortic Dissection (late), Coronary Ischemia, Esophageal Rupture, Pericarditis, Myocarditis
Tachycardia – Acute MI, PE, Aortic Dissection, Coronary Ischemia, Tension Pneumothorax, Esophageal Rupture, Coronary Spasm, Pericarditis, Myocarditis, Mediastinitis, Cholecystitis,
Bradycardia – Esophageal Tear (Mallory-Weiss), Acute MI, Unstable Angina
Hypertension – Acute MI, Coronary Ischemia, Aortic Dissection (early)
Fever – PE, Esophageal Rupture, Pericarditis, Myocarditis, Mediastinitis, Cholecystitis,
Hypoxemia – PE, Tension Pneumothorax, Pneumothorax

16. Sorting It All Out… Helpful Physical Exam findings Cardiovascular Exam
Asymmetric Upper Extremity Blood Pressures
Narrow Pulse Pressure
New Murmur
S3/S4 Gallop
Pericardial Rub
Audible Systolic “Crunch” (Hamman’s Sign)
JVD
Pulmonary Exam
Unilateral Diminished Breath Sounds
Pleural Rub
Subcutaneous Emphysema
Rales
Asymmetric Pressures – Aortic Dissection
Narrow Pulse Pressure – Pericarditis (with effusion)
New Murmur – Acute MI, Aortic Dissection, Coronary Ischemia
S3/S4 Gallop – Acute MI, Coronary Ischemia
Pericardial Rub – Pericarditis
Audible Crunch – Esophageal Rupture, Mediastinitis,
JVD – Acute MI, Coronary ischemia, Tension Pneumothorax, PE, Pericarditis
Unilateral Diminished BS – Tension Pneumothorax, Pneumothorax
Pleural Rub – PE
Subcutaneous Emphysema – Tension Pneumothorax, Esophageal Rupture, Pneumothorax, Mediastinitis
Rales – Acute MI, Coronary Ischemia, Unstable Angina

17. Sorting It All Out… Helpful Physical Exam findings Abdominal Exam
Epigastric Tenderness
LUQ Tenderness
RUQ Tenderness
Neurologic Exam
Focal Findings
Stroke
Epigastric Tenderness – Esophageal Rupture, Esophageal Tear, Cholecystitis, Pancreatitis
LUQ Tenderness – Pancreatitis
RUQ Tenderness – Cholecystitis
Focal Findings – Aortic Dissection
Stroke – Acute MI, Coronary Ischemia, Aortic Dissection, Coronary Spasm

18. Sorting It All Out… Field Evaluation EKG
Should be performed within 10 minutes of patient contact
All male patients >33 years old and all female patients >39 years old with a pain complaint between the jaw and the belly button
Time lost is muscle lost!
New Injury Pattern
Right Heart Strain
Diffuse ST segment elevation
New Injury Pattern – suggestive of MI, should have therapy initiated immediately; notification of appropriate facility, activation of cath lab if available
Right Heart Strain – consider PE
Diffuse ST Elevation – consider pericarditis

19. Sorting It All Out… Prehospital Emergency Care March 19, 2013
“Field Activation of the Cath Lab Improves Door-to-Balloon Time”
Small, prospective observational study
Paramedics trained to interpret 12-leads were permitted to bypass the ED and transport directly to the cath lab
38 prehospital activations, 47 activations after arrival and 28 walk- ins
90 minute door-to-balloon benchmark was met 100% of the time when activated ahead of time
72% for activation after arrival
68% for walk-ins

20. Sorting It All Out…
What are the “can’t miss” causes of chest pain and SOB I need to worry about?
Myocardial Infarction
Unstable Angina
Aortic Dissection
Pulmonary Embolism
Pneumothorax
Esophageal Rupture
Pericarditis

21. Sorting It All Out…
What are the “can’t miss” causes of chest pain and SOB I need to worry about?
Myocardial Infarction
Myocardial infarction
pain is moderately severe and rapid in onset. May be more pressure than pain. Usually retrosternal with radiation to neck, jaw, arms, epigastrium. Lasts more than minutes and unrelieved by NTG.
associated symptoms diaphoresis, nausea, vomiting, shortness of breath
supporting history – may be brought on by emotional stress or exertion. Prodromal pain pattern usually elicited in history. Age >40, risk factors and male sex increase possibility.
physical exam – patients are anxious and uncomfortable. May be diaphoretic and show poor peripheral perfusion. No diagnostic physical exam findings for acute MI, but S3 and S4 heart sounds are supportive.
EKG is the most useful test, changes seen in 80% of patients.

22. Sorting It All Out…
What are the “can’t miss” causes of chest pain and SOB I need to worry about?
Unstable Angina
Unstable Angina
Changes in the pattern of angina with more severe, more prolonged or more frequent pain. Pain usually lasts >10 minutes. Unpredictable responses to NTG and rest.
associated symptoms may be minimal; may have mild diaphoresis, nausea, SOB. May have increasing DOE
supporting history – no clear relation to precipitating factors. Previous history of MI, age >40, risk factors, male sex all increase probability.
physical exam – nonspecific findings of transient nature, may be similar to MI
EKG may be nonspecific or nondiagnostic

23. Sorting It All Out…
What are the “can’t miss” causes of chest pain and SOB I need to worry about?
Aortic Dissection
Aortic Dissection
90% of patients have rapid onset of severe pain that is maximal at the beginning. Pain may radiate to the back or abdomen. May be described as “tearing” and pain may migrate
associated symptoms neurologic complaints – stroke, peripheral neuropathy, paresis or paraplegia related to dissection of vessels supplying the brain or spinal cord, poor peripheral pulses possible
supporting history – median age is 59, history of HTN in 70-90% of patients, 3:1 ratio male:female, Marfan syndrome and bicuspid aortic valve have increased incidence
physical exam – elevated BP but poor peripheral perfusion % of cases have asymmetrically decreased or absent peripheral pulses. 1-2% will also have coronary occlusion, renal, spinal cord insufficiency
EKG usually shows LVH, nonspecific.
Ascending aortic aneurysms are usually managed surgically, descending aneurysms are usually managed medically

24. Sorting It All Out…
What are the “can’t miss” causes of chest pain and SOB I need to worry about?
Pulmonary Embolism
Pulmonary Embolism
Pain is often lateral and pleuritic in nature, central pain could be a massive clot. Pain usually abrupt in onset and maximal at the beginning.
associated symptoms dyspnea and apprehension are most prominent. “I feel like I’m going to die”. Cough is present in ~1/2 of cases. Hemoptysis occurs in <20%. May mimic angina in 5%
supporting history – often a history of immobilization can be obtained, or pregnancy, OCPs, CA are all risk factors. Previous DVT or PE is the greatest risk factor
physical exam – anxiety with an increased RR. Tachycardia, inspiratory rales, fever, phlebitis and diaphoresis in 30-40%
patients may have SOB with or without bronchospasm. Acute mortality is 10%. Source is usually from lower extremities or pelvis. May be a subtle cause of COPD exacerbation.

25. Sorting It All Out…
What are the “can’t miss” causes of chest pain and SOB I need to worry about?
Pneumothorax
Pneumothorax
pain is usually acute and maximal at onset. Most often lateral but can be central in a large PTX
dyspnea is the prominent symptom. Hypotension and AMS can occur with tension PTX.
supporting history – chest trauma, previous pneumothorax or tall, thin body type
physical exam – unilateral decreased BS. Elevated pressure, distended neck veins, tachycardia and hypotension in tension PTX
may be subtle in COPD, asthma, CF.

26. Sorting It All Out…
What are the “can’t miss” causes of chest pain and SOB I need to worry about?
Esophageal Rupture
Esophageal Rupture
pain is preceeded by vomiting and abrupt in onset. Persistent and unrelieved, increased with swallowing and neck flexion
diaphoresis and pain are the prominent symptoms. Can have dyspnea (late) and shock
supporting history – older individuals with known GI problems. History of violent vomiting, esophageal foreign body, caustic ingestion, blunt trauma, alcoholism
physical exam – subcutaneous emphysema, ? Signs of lung consolidation
patients may present in shock. Rare, often considered late in the differential process

27. Sorting It All Out…
What are the “can’t miss” causes of chest pain and SOB I need to worry about?
Pericarditis
Pericarditis
dull, achy chest pain unrelated to exercise or eating. Does not change with chest wall motion, not relieved by NTG
SOB and diaphoresis are the prominent symptoms
supporting history – pain is worse when laying flat, improved with sitting up. Often preceded by viral illness or underlying disease (SLE, uremia).
physical exam – friction rub may be present, more prominent with positions
EKG will demonstrate ST elevation across precordial leads. More common in y/o. Idiopathic is the most common etiology, may have associated ventricular dysrhythmias

28. Sorting It All Out… Summary Chest Pain and Shortness of Breath
Very common reasons to seek medical treatment
NOT very easy to sort out
Etiology from the benign to the immediately life threatening
The burden is on us the medical providers to figure out what’s happening with the patients
Most of the answer comes through the history and 12-lead
If you don’t act on the information you get, the patient can arrest!

29. Sorting It All Out…

30. Sorting It All Out… Quotable
“I never did a day’s work in my life. It was all fun.”
-Thomas Edison

31. Sorting It All Out…
Thank You!

34. References
CONE DC, Lee CH, Van Gelder C 
EMS activation of the cardiac catheterization laboratory is associated with process improvements in the care of myocardial infarction patients.
Prehosp Emerg Care. 2013;17:293-8.
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