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

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Presentation on theme: "Sorting It Out: Chest Pain, Cardiac Arrest and SOB Michael Lohmeier, MD June 24, 2014."— Presentation transcript:

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

3 Sorting It All Out…  Before I begin…  Thank You for this opportunity  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

4 Sorting It All Out… PPer the Wisconsin EMS Association Website 5598,416 calls for EMS in 2011 115% increase from 2010 440% of calls are responded to by 10 services in the state IIn 1992, only 9% of Wisconsin ambulance services operated at the Paramedic level TToday, 32% of services are licensed at this level 6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 TThat’s 59,000 patients per year! https://www.wisconsinems.com/ems-for-the-general-public/wisconsin-ems-statistics/

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

6 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

7 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

8 Sorting It All Out…  Differentials  Chest Pain  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…  Differentials  Chest Pain  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

10 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

11 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

12 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.

13 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!

14 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?

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

16  Helpful Physical Exam findings  Appearance  Acute Respiratory Distress  Diaphoresis  Vital Signs  Hypotension  Tachycardia  Bradycardia  Hypertension  Fever  Hypoxemia

17 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

18 Sorting It All Out…  Helpful Physical Exam findings  Abdominal Exam  Epigastric Tenderness  LUQ Tenderness  RUQ Tenderness  Neurologic Exam  Focal Findings  Stroke

19 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

20 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

21 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

22 Sorting It All Out…  What are the “can’t miss” causes of chest pain and SOB I need to worry about?  Myocardial Infarction

23 Sorting It All Out…  What are the “can’t miss” causes of chest pain and SOB I need to worry about?  Unstable Angina

24 Sorting It All Out…  What are the “can’t miss” causes of chest pain and SOB I need to worry about?  Aortic Dissection

25 Sorting It All Out…  What are the “can’t miss” causes of chest pain and SOB I need to worry about?  Pulmonary Embolism

26 Sorting It All Out…  What are the “can’t miss” causes of chest pain and SOB I need to worry about?  Pneumothorax

27 Sorting It All Out…  What are the “can’t miss” causes of chest pain and SOB I need to worry about?  Esophageal Rupture

28 Sorting It All Out…  What are the “can’t miss” causes of chest pain and SOB I need to worry about?  Pericarditis

29 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!

30 Sorting It All Out…

31  Quotable  “I never did a day’s work in my life. It was all fun.” -Thomas Edison

32 Sorting It All Out… TThank You!

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35  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:    education/image?DOCID=10087&PAGE=en_%7B e-d597-4edd-b169- dd09df788588%7D.jpg&module=patEdu education/image?DOCID=10087&PAGE=en_%7B e-d597-4edd-b169- dd09df788588%7D.jpg&module=patEdu      


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