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

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

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! https://www.wisconsinems.com/ems-for-the-general-public/wisconsin-ems-statistics/

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

Sorting It All Out… Why should you care? Chest Pain is one of the most common reasons for activating 9- 1-1 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 2010. For the non-traumatic visits, chest pain was #2 and shortness of breath was #6 http://www.cdc.gov/nchs/fastats/emergency-department.htm http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2010_ed_web_tables.pdf

Sorting It All Out… Chest Pain, Shortness of Breath and Cardiac Arrest can be on a spectrum of cardiac ischemia – or completely unrelated! Approximately 129.8 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 http://www.cdc.gov/nchs/fastats/emergency-department.htm

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

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

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

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

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. http://healthinessbox.files.wordpress.com/2012/09/chest_pain.jpg

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!

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. http://www.emtresource.com/resources/acronyms/opqrst/

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

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

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

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

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

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

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

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 15-30 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.

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

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. 50-60% 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

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.

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.

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

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 20-50 y/o. Idiopathic is the most common etiology, may have associated ventricular dysrhythmias

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!

Sorting It All Out…

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

Sorting It All Out… Thank You!

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.
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