Hawaii State EMS Chest Pain Standing Order Review Prepared for Honolulu Emergency Medical Services Presented by Dr. Joseph Lewis, M.D., Medical Director, Honolulu Emergency Services, September, 2014

Objectives: Four 1. Review what types of patients have cardiac chest pain. 2. Review State of Hawaii Standing Orders for chest pain. 3. Understand how it follows a clinical standard written by the American Heart Association (AHA), the American College of Cardiology (ACC) and the European Heart Association (EHA). 4. Understand the importance of aspirin. 5. Remember the ADR's of EMS: Assess, Do and Reassess.

Who can have cardiac chest pain? Cardiac disease is not confined to men over age 50. We have to think about cardiac disease as a cause of chest pain in people over 28, both men and women, due to many factors including: cholesterol and lipid disorders, genetic disorders, tobacco, cocaine and methamphetamines. In rare circumstances conditions like Kawasaki’s disease attacks the coronary arteries supplying blood to the heart of children. So even children can have cardiac chest pain under that rare circumstance. But more common causes of cardiac chest pain in children include pericarditis, myocarditis and cardiac tachydysrhythmias. So a minimal assessment includes noninvasive tests like a cardiac monitor and an EKG. These are painless and can save a life. Also be aware of atypical presentations in women and patients with diabetes. In these groups dyspnea or shortness of breath may be the presenting complaint of a heart attack.

The American Heart Association (AHA), the American College of Cardiology (ACC) and, the European Heart Association (EHA) have agreed to certain established standards for the care of suspected cardiac chest pain, which is supported by scientific articles from America, Europe and Asia. These guidelines are straight forward and effective. The guideline for suspected cardiac chest pain includes a medication regiment which is often abbreviated as MONA. The American Heart Association (AHA), the American College of Cardiology (ACC) and, the European Heart Association (EHA) have agreed to certain established standards for the care of suspected cardiac chest pain, which is supported by scientific articles from America, Europe and Asia. These guidelines are straight forward and effective. The guideline for suspected cardiac chest pain includes a medication regiment which is often abbreviated as MONA.

The guideline includes EKG, vital signs, cardiac monitoring, IV access and MONA. MONA Stands for: Morphine Morphine Oxygen Nitrates Aspirin

This is the Hawaii State EMS standing order for chest pain.

The standing order for chest pain can be distilled down to these actions. 1. Oxygen 2. EKG, transmit if a STEMI 3. Nitrates, unless hypotensive, ED Drugs or RV Infarct 4. Aspirin, unless allergic or recent GI bleed 5. IV 6. Communicate with Base Station Physician for further orders or to give an alert. The above actions are part of the standard EMS Assess-Do-Reassess protocol for proper care of the patient. (Also called EMS ADR’s) Always assess the effect of your interventions on the patient and assess for changes in the patient, like going into ventricular tachycardia or losing consciousness.

Our Standing Orders for suspected cardiac chest pain borrows from this guideline because it is evidence based and proven to be effective. O. Oxygen relieves cardiac chest pain and decreases dysrhythmias. N. Nitrates reduce blood return to the heart (Preload) and widens the blood vessels which supply to blood to the heart. Contraindications: right ventricular infarct, use of drugs for erectile dysfunction and hypotension. A. Aspirin is used to inhibit platelet function. This stops clots in the blood vessels which supply blood to the heart from getting bigger and further reducing blood flow to the heart. These clots would grow and eventually close off the artery or arteries involved in the heart attack. This action is so important that aspirin saves more lives than Tissue Plasminogenase Activator (TPA) and emergent cardiac catherization put together.

Aspirin Many large clinical studies show that most people with cardiac chest pain have blood clots in the arteries which supply blood to the heart. Tragically these clots reduce blood flow. Fortunately the majority of patients can safely be given aspirin, which stops these clots from getting larger. Unfortunately only a small number of people with cardiac chest pain qualify for the other two major treatments which save lives: the drug T.P.A. and the surgical procedure cardiac catherization. Aspirin is cheap, easy to give and hundreds of studies show it saves lives. Surprisingly the dose needed to save a life is very small: 162 milligrams. That dose is one half of a regular adult aspirin. The usual dose taken by an adult for a headache is 650 to 975 mg. It is remarkable that a dose of 162 mg can save a life, while a dose 5 times that size helps a headache. So remember giving an extra dose of 162 mg is harmless and most importantly it could save their life.

Aspirin and GI bleeding. In the case of a patient with gastrointestinal bleeding in the past, but no bleeding for six months, there is no scientific evidence that giving one half an adult aspirin to them will cause them any harm. However, there is plenty of evidence that the same patient will benefit greatly from that half an aspirin.

Follow EMS standing orders. Follow EMS A.D.R. protocols Assess, Do, Reassess. Assess the patient, which includes history taking, medication review, listening to heart and lungs, plus vital signs. Do includes EKG, cardiac monitor, IV, morphine, oxygen, nitrates and aspirin. Reassess, includes asking the patient how they are doing, repeat vitals, observe the monitor, check pulse oximetry and possibly capnography. The journey towards better cardiac disease survival starts with you.

Questions? Any questions? Dr. Lewis Remember the ADR’s Assess, Do, Reassess!