Presentation on theme: "Sorting It Out: Chest Pain, Cardiac Arrest and SOB"— Presentation transcript:
1 Sorting It Out: Chest Pain, Cardiac Arrest and SOB Michael Lohmeier, MDJune 24, 2014
2 Sorting It All Out… Thank You for this opportunity Before I begin… A Little About Me…Michael LohmeierAssistant Professor of Medicine, Emergency MedMedical Director; Madison Fire, FitchRona EMS, Middleton EMS, Dane County EMS, UW PD First RespondersMedical Director, University of Wisconsin EECDirector, EMS Rotation for Residents
3 Sorting It All Out… Per the Wisconsin EMS Association Website 598,416 calls for EMS in 201115% increase from 201040% of calls are responded to by 10 services in the stateIn 1992, only 9% of Wisconsin ambulance services operated at the Paramedic levelToday, 32% of services are licensed at this level68% 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” situationsThat’s 59,000 patients per year!https://www.wisconsinems.com/ems-for-the-general-public/wisconsin-ems-statistics/
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 activatingUnofficial Dane County DataEmergency Department dataNot everything that presents with chest pain is cardiacTime lost is muscle lostEMS is triaged to cardiac cath labs in many parts of the stateThe public expects you to get it rightMisdiagnosing an MI can be deadly!Aortic dissectionPericarditisDane 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 20105.4% of visits for chest pain2.7% of visits for shortness of breath2.7% of visits for coughCritical diagnoses causing either varies widelyACS, aortic dissection, pulmonary embolism, tension pneumothorax, pericardial tamponade, esophageal rupture
7 Sorting It All Out… Differentials Chest Pain Shortness of Breath Acute MIUnstable AnginaPEAortic DissectionPneumothoraxCardiac TamponadeEsophageal RupturePericarditisShortness of BreathAsthma and COPDPneumoniaPneumothoraxPulmonary EmbolismTraumaAcute Coronary SyndromeEndocrine (DKA, metabolic acidosis)Hematologic (anemia)Toxins (Salicylate overdose)Ascites
8 Sorting It All Out… Differentials Chest Pain Shortness of Breath Acute MIUnstable AnginaPEAortic DissectionPneumothoraxCardiac TamponadeEsophageal RupturePericarditisShortness of BreathAsthma and COPDPneumoniaPneumothoraxPulmonary EmbolismTraumaAcute Coronary SyndromeEndocrine (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 brainFibers from the heart, lungs, great vessels and esophagus enter the same thoracic dorsal gangliaThese ganglia overlap the 3 segments above and belowLocation and quality of the pain are indistinct to the patientCan be from the jaw to the epigastriumSome somatic afferent fibers synapse in the same dorsal root ganglia and can “confuse” the CNSGives 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 reactionNeither the clinical severity nor the patient’s perception correlates well with the seriousness of underlying pathologyThe actual mechanisms for dyspnea are unknownImbalance between the respiratory center in the medulla oblongata and the chemoreceptors near the carotid bodiesIncreased work of breathingIncreased respiratory drive
11 Sorting It All Out… Just to recap… Chest Pain is indistinct to the patient, source may be unclear on examDyspnea is subjective, may be related to a physical, metabolic or psychiatric conditionDifferential is enormous, from non-emergent to the most critical diagnoses in medicineAwesome.
12 Sorting It All Out…What are the life threats, and does this patient need an intervention immediately?There is no simple algorithmKeep your approach organized and systematicKeys to narrow down your differential will be in the history, physical exam and EKG in ~90% of patientsMajority of diagnosis is going to come from the historyIf they’re already in cardiac arrest, run the ACLS algorithmsDesigned to treat the underlying etiologiy of arrestWe 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 palliationWhat makes the pain better or worse?QualityCan you describe the pain? Sharp, dull, achy, stabbing, burning?Region and RadiationWhere is the pain, and does it go anywhere?SeverityOn a scale of 0-10 with zero being no pain, how bad does this hurt?TimingHow 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 sourcePain 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 causesSqueezing, 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 sourcePain 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 causeSeverity of pain should be documented at onset, peak, present and after interventionsPain 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 differentialBut beware – the biggest barrier to making the correct diagnosis is…The previous diagnosis!!Associated symptoms may be helpful as wellDiaphoresis should suggest a serious or visceral causeHemoptysis is a classic PE sign – that is seen in about 1/5 the timeNausea and Vomiting can be GI or cardiac in natureRisk factors are important to consider when evaluating a patientGood to know from a population basis, not as helpful with the individual
18 Sorting It All Out… Field Evaluation EKG Should be performed within 10 minutes of patient contactAll male patients >33 years old and all female patients >39 years old with a pain complaint between the jaw and the belly buttonTime lost is muscle lost!New Injury PatternRight Heart StrainDiffuse ST segment elevationNew Injury Pattern – suggestive of MI, should have therapy initiated immediately; notification of appropriate facility, activation of cath lab if availableRight Heart Strain – consider PEDiffuse 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 studyParamedics trained to interpret 12-leads were permitted to bypass the ED and transport directly to the cath lab38 prehospital activations, 47 activations after arrival and 28 walk- ins90 minute door-to-balloon benchmark was met 100% of the time when activated ahead of time72% for activation after arrival68% 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 InfarctionUnstable AnginaAortic DissectionPulmonary EmbolismPneumothoraxEsophageal RupturePericarditis
21 Sorting It All Out…What are the “can’t miss” causes of chest pain and SOB I need to worry about?Myocardial InfarctionMyocardial infarctionpain 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 breathsupporting 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 AnginaUnstable AnginaChanges 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 DOEsupporting 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 MIEKG 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 DissectionAortic Dissection90% 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 migrateassociated symptoms neurologic complaints – stroke, peripheral neuropathy, paresis or paraplegia related to dissection of vessels supplying the brain or spinal cord, poor peripheral pulses possiblesupporting 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 incidencephysical 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 insufficiencyEKG 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 EmbolismPulmonary EmbolismPain 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 factorphysical 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?PneumothoraxPneumothoraxpain is usually acute and maximal at onset. Most often lateral but can be central in a large PTXdyspnea is the prominent symptom. Hypotension and AMS can occur with tension PTX.supporting history – chest trauma, previous pneumothorax or tall, thin body typephysical exam – unilateral decreased BS. Elevated pressure, distended neck veins, tachycardia and hypotension in tension PTXmay 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 RuptureEsophageal Rupturepain is preceeded by vomiting and abrupt in onset. Persistent and unrelieved, increased with swallowing and neck flexiondiaphoresis and pain are the prominent symptoms. Can have dyspnea (late) and shocksupporting history – older individuals with known GI problems. History of violent vomiting, esophageal foreign body, caustic ingestion, blunt trauma, alcoholismphysical exam – subcutaneous emphysema, ? Signs of lung consolidationpatients 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?PericarditisPericarditisdull, achy chest pain unrelated to exercise or eating. Does not change with chest wall motion, not relieved by NTGSOB and diaphoresis are the prominent symptomssupporting 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 positionsEKG 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 treatmentNOT very easy to sort outEtiology from the benign to the immediately life threateningThe burden is on us the medical providers to figure out what’s happening with the patientsMost of the answer comes through the history and 12-leadIf you don’t act on the information you get, the patient can arrest!
34 ReferencesCONE 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.education/image?DOCID=10087&PAGE=en_%7B e-d597-4edd-b169- dd09df788588%7D.jpg&module=patEdu