Chest Pain Chest Pain Differentiating Causes and Patient Presentations June 2009

Objectives Differentiate the characteristics of cardiac and non cardiac causes of chest pain Differentiate the characteristics of cardiac and non cardiac causes of chest pain Identify gender,age and differences in presentation of cardiac related chest pain Identify gender,age and differences in presentation of cardiac related chest pain Discuss the Kaleida Health Chest Pain protocol Discuss the Kaleida Health Chest Pain protocol

Patient Scenario #1 A 62 year old male presents A 62 year old male presents to you with a tingling to you with a tingling sensation in his neck- sensation in his neck- he points to the area he points to the area of the carotid arteries. He has a vague of the carotid arteries. He has a vague sense that something is wrong…..what will you do?? sense that something is wrong…..what will you do??

Patient Scenario #2 A 32 year old female complains of extreme fatigue. Her resting heart rate is 125 and she feels “lightheaded”… A 32 year old female complains of extreme fatigue. Her resting heart rate is 125 and she feels “lightheaded”… What else do you want to know? What else do you want to know?

Patient Scenario #3 A 38 year old construction worker complains of a work related injury. He has tearing like pain in his shoulder that radiates to his back…What other assessments will you perform? A 38 year old construction worker complains of a work related injury. He has tearing like pain in his shoulder that radiates to his back…What other assessments will you perform?

Sources of Chest Pain Pain in the chest can originate from many body systems, including the heart Cardiac Cardiac Pulmonary Pulmonary Gastrointestinal Gastrointestinal Metabolic Metabolic Musculoskeletal Musculoskeletal Hematological Hematological

Non Cardiovascular causes of chest pain… a multi system diagnostic dilemma Pulmonary Pulmonary Pulmonary Embolism, Pulmonary Hypertension, Pneumothorax, Pleuritis, Pneumonia Pulmonary Embolism, Pulmonary Hypertension, Pneumothorax, Pleuritis, Pneumonia Gastrointestinal Gastrointestinal GERD, Esophageal rupture,Peptic Ulcer, Esophageal spasm, Pancreatitis, Cholecystitis GERD, Esophageal rupture,Peptic Ulcer, Esophageal spasm, Pancreatitis, Cholecystitis

Non Cardiovascular causes of chest pain… a multi system diagnostic dilemma Hematologic Hematologic severe anemia, sickle cell crisis severe anemia, sickle cell crisis Musculoskeletal Musculoskeletal Costochrondritis, rib fractures Costochrondritis, rib fractures

Cardiac related chest pain..still many potential causes… Myocardial Infarction Myocardial Infarction Unstable Angina Unstable Angina Pericarditis Pericarditis Cardiac Tamponade Cardiac Tamponade Aortic Stenosis & Dissection Aortic Stenosis & Dissection Cardiomyopathy Cardiomyopathy

APQRST a Mnemonic for the evaluation of Chest Pain A= Associated symptoms P= Precipitating factors and palliation Q= Quality R= Region,radiation S= Severity T= Timing

Associated symptoms- Circulatory Tachycardia/Bradycardia Tachycardia/Bradycardia Hypertension/Hypotension Hypertension/Hypotension Palpitations Palpitations Change in heart sounds- murmur,rub,distant or muffled Change in heart sounds- murmur,rub,distant or muffled

Associated symptoms- Pulmonary Shortness of breath Shortness of breath Dyspnea Dyspnea Decreased or absent breath sounds Decreased or absent breath sounds Crackles, wheezing to auscultation Crackles, wheezing to auscultation Cough Cough

Associated Symptoms-Neurologic Change in mental status Change in mental status Dizziness Dizziness Syncope Syncope

Additional Associated symptoms Fatigue Fatigue Sleep disturbance Sleep disturbance Weakness Weakness Nausea and vomiting Nausea and vomiting Diaphoresis Diaphoresis Anxiety-impending doom Anxiety-impending doom

Precipitating Factors/Palliation Exertion Exertion Eating Eating Cold exposure Cold exposure Activity/Movement/Change of position Activity/Movement/Change of position Palpation Palpation Inspiration Inspiration

Precipitating Factors/Palliation Relieved with: Rest Rest Position change Position change Nitroglycerine Nitroglycerine Antacid Antacid

Quality Heaviness Heaviness Crushing Crushing Tight/Squeezing Tight/Squeezing Stabbing Stabbing Burning Burning Sharp/dull Sharp/dull Aching Aching Pressure Pressure Numbness Numbness

Region,Radiation Located Located substernal, retrosternal, left or right chest,midback, shoulder, neck, jaw substernal, retrosternal, left or right chest,midback, shoulder, neck, jaw Radiates to Radiates to jaw, arm, back, shoulder, abdomen,neck jaw, arm, back, shoulder, abdomen,neck

Severity Use the 0-10 faces/numeric scale Use the 0-10 faces/numeric scale

Timing Onset and duration Onset and duration Gradual or sudden Gradual or sudden Intermittent or constant Intermittent or constant Nocturnal Nocturnal

Typical signs and symptoms associated with Acute Coronary Syndrome (ACS) Crushing, oppressive, or constricting pain or feeling, or pressure that may radiate to left arm, neck and jaw, shoulder or epigastric area Crushing, oppressive, or constricting pain or feeling, or pressure that may radiate to left arm, neck and jaw, shoulder or epigastric area Nausea, vomiting, diaphoresis, palpitations, dyspnea Nausea, vomiting, diaphoresis, palpitations, dyspnea Cool, clammy skin Cool, clammy skin

Gender differences in ACS presentation Both men and women may present with “classic” chest pain, diaphoresis, SOB Both men and women may present with “classic” chest pain, diaphoresis, SOB Women may have more jaw and neck pain Women may have more jaw and neck pain Women may have a greater tendency to have atypical chest pain-abdominal pain dyspnea, nausea/indigestion, unexplained /unusual fatigue,numbness in the hands,palpitations* Women may have a greater tendency to have atypical chest pain-abdominal pain dyspnea, nausea/indigestion, unexplained /unusual fatigue,numbness in the hands,palpitations* *This rather vague group of symptoms is is considered atypical and is common to many less serious health problems. DeVon,Ryan,Ochs,Shapiro AJCC January 2008 Volume 17 No.1 DeVon,Ryan,Ochs,Shapiro AJCC January 2008 Volume 17 No.1

Age variation in ACS presentation Symptoms experienced by older adults (age > 65) are more diffuse and and potentially milder Symptoms experienced by older adults (age > 65) are more diffuse and and potentially milder Fatigue and SOB (breathlessness) Fatigue and SOB (breathlessness) were major presenting symptoms, only were major presenting symptoms, only 55% had chest pain 55% had chest pain Lindgren et al Nursing Research January/February 2008 Vol 57 No.1 Lindgren et al Nursing Research January/February 2008 Vol 57 No.1

Other impacts on ACS presentation Diabetes-( neuropathy) more likely to present with weakness, dyspnea and nausea Diabetes-( neuropathy) more likely to present with weakness, dyspnea and nausea Hypertension, prior stroke and heart failure may cause decrease in perceived chest pain Hypertension, prior stroke and heart failure may cause decrease in perceived chest pain DeVon & Ryan: Journal of Cardiovascular Nursing July/August 2005 Vol 20 No.4

Patient Scenario #1 A 62 year old male presents A 62 year old male presents to you with a tingling to you with a tingling sensation in his neck- sensation in his neck- he points to the area he points to the area of the carotid arteries. He has a vague of the carotid arteries. He has a vague sense that something is wrong…..what sense that something is wrong…..what else do you want to know? else do you want to know?

Patient Scenario #1 A 68 year old male presents A 68 year old male presents to you with a tingling to you with a tingling sensation in his neck- sensation in his neck- he points to the area he points to the area of the carotid arteries. He has a vague of the carotid arteries. He has a vague sense that something is wrong…..what sense that something is wrong…..what else do you want to know?? else do you want to know?? Is he diabetic ? Do the APQRST Is he diabetic ? Do the APQRST

Patient Scenario #2 A 32 year old female complains of extreme fatigue. Her resting heart rate is 125 and she feels “lightheaded”… A 32 year old female complains of extreme fatigue. Her resting heart rate is 125 and she feels “lightheaded”… Does her age mean that she is not having a cardiac event? Does her age mean that she is not having a cardiac event?

Patient Scenario #2 A 32 year old female complains of extreme fatigue. Her resting heart rate is 125 and she feels “lightheaded”… Does her age mean she is not having a cardiac event? A 32 year old female complains of extreme fatigue. Her resting heart rate is 125 and she feels “lightheaded”… Does her age mean she is not having a cardiac event?No- When did the symptoms begin? Was it a sudden onset? Finish the APQRST

Patient Scenario #3 A 38 year old construction worker complains of a work related injury. He has tearing like pain in his shoulder that radiates to his back…What other assessments will you perform? A 38 year old construction worker complains of a work related injury. He has tearing like pain in his shoulder that radiates to his back…What other assessments will you perform?

Patient Scenario #3 A 38 year old construction worker complains of a work related injury. He has tearing like pain in his shoulder that radiates to his back…What other assessments will you perform? A 38 year old construction worker complains of a work related injury. He has tearing like pain in his shoulder that radiates to his back…What other assessments will you perform? Assess character, radiation,intensity and onset of the pain. Assess vital signs Ask about what activity he feels initiated the pain Finish the APQRST…

Chest Pain Remember that Chest Pain may indicate a critical lack of oxygen to the heart Remember that Chest Pain may indicate a critical lack of oxygen to the heartOr… Be a result of an alteration in another body system Be a result of an alteration in another body systemHowever All chest pain should be treated as cardiac until proven otherwise All chest pain should be treated as cardiac until proven otherwise

Chest Pain Protocol A. Assessment/Data Collection: Assess with onset of chest pain: Assess with onset of chest pain: Location, radiation, character, duration, intensity, skin temp, color, nausea, vomiting, diaphoresis, shortness of breath, precipitating factors (i.e. movement, deep inspiration, palpitation), relieving factors, and any similarities to previous pain. Location, radiation, character, duration, intensity, skin temp, color, nausea, vomiting, diaphoresis, shortness of breath, precipitating factors (i.e. movement, deep inspiration, palpitation), relieving factors, and any similarities to previous pain. KEYPOINT: Ask the patient to rate the pain on a scale from 1-10, 10 being the worst possible pain, and document on appropriate flowsheet. BP, HR, RR, and heart rhythm (if on monitor) BP, HR, RR, and heart rhythm (if on monitor) Evaluate BP before and five (5) minutes after each administration of antianginal medication (If physician has ordered these medications). Evaluate BP before and five (5) minutes after each administration of antianginal medication (If physician has ordered these medications). Assess for pain relief and any associated symptoms after each administration of antianginal medications (If physician has ordered these medications). Assess for pain relief and any associated symptoms after each administration of antianginal medications (If physician has ordered these medications). Vital signs Q4H. Vital signs Q4H.

Chest Pain Protocol B. Care and Management: Administer Oxygen at 2 L/minute until physician order received. Administer Oxygen at 2 L/minute until physician order received. Obtain ECG for all occurrences of new onset and recurrent, unresolved chest pain. Obtain ECG for all occurrences of new onset and recurrent, unresolved chest pain. KEYPOINT: In long-term care, obtain physician order for ECG. Maintain bedrest during episode of acute pain. Maintain bedrest during episode of acute pain. Maintain quiet and restful environment during episode of pain. Maintain quiet and restful environment during episode of pain. Provide reassurance to the patient and family. Provide reassurance to the patient and family.

Chest Pain Protocol C. Complications/Reportable Situations: C. Complications/Reportable Situations: Notify physician/ licensed independent practitioner for: all occurrences of new onset/unresolved chest pain and associated assessment. all occurrences of new onset/unresolved chest pain and associated assessment. changes in heart rhythm (when patient is continuously monitored). changes in heart rhythm (when patient is continuously monitored). deterioration of vital signs from baseline. deterioration of vital signs from baseline. D.Safety and Prevention: D.Safety and Prevention: Avoid valsalva maneuver.

Chest Pain Protocol Patient/Family Education: Instruct patient and/or significant other to: inform a staff member of all episodes of chest discomfort or associated symptoms. inform a staff member of all episodes of chest discomfort or associated symptoms. inform a staff member immediately after taking NTG, if ordered at the bedside. inform a staff member immediately after taking NTG, if ordered at the bedside. maintain bedrest during episode of chest pain. maintain bedrest during episode of chest pain. avoid valsalva maneuvers. avoid valsalva maneuvers.