Chest Pain and the BLS Provider By Daniel B. Green II, NREMT-P, CCP

Objectives Review Cardiac A & P Discuss common causes of chest pain Discuss the BLS assessment of the chest pain patient Discuss less common presentations of cardiac patients Discuss BLS treatment of the chest pain patient

Heart Disease Still leading cause of death in the United States Survivability is increasing due to research Treatment of MIs is currently concentrating on reperfusion in Cath Labs Physicians are emphasizing risk factor modification to prevent disease

Risk Factors Diabetes Hypertension Increased Cholesterol and Lipids Family History Known Coronary Artery Disease Obesity Smoking Sedentary Lifestyle Carbohydrate Intolerance Personality Type Poor Diet Stress/Tension Oral Contraceptive Use

Prevention Strategies Educational Programs –Nutrition –Smoking Cessation Recognition of Symptoms and Prompt Intervention

Cardiac Anatomy and Physiology Heart is located in the mediastinum 2/3 of mass to the left of the midline Top is the base Bottom is the apex About the size of the fist

Cardiac Anatomy and Physiology Epicardium –Outermost layer (Visceral Pericardium) Myocardium –Thick middle layer Endocardium –Smooth, inner layer of connective tissue

Chambers of the Heart Atria –Superior chambers –Less muscular Ventricles –Inferior chambers –More muscular Left is 3 times thicker than right

Heart Valves Primary Function –Prevent blood from flowing backward AV valves –Between atria and ventricles –Tricuspid (Right) –Mitral (Left) Semiluner Valves –Pulmonic –Aortic

Cardiac Physiology Two pump system –Low Pressure (Right Side) –High Pressure (Left Side) Circulates blood throughout body to carry oxygen to tissues and remove waste Let’s trace a drop of blood through the body

Coronary Arteries Carry ml each minute Left coronary artery carries 85% –LAD –Circumflex Right coronary carries remaining volume

Conduction System Cardiac muscle is unique –Automaticity –Excitability –Conductivity –Contractility

Conduction System Sinoatrial node (SA) –Primary pacemaker –Inherent rate Atrioventricular Junction –Inherent rate –AV Node and Bundle of His Ventricular Sites –Inherent rate 20-30

Initial Cardiac Assessment Level of consciousness (AVPU) Airway Breathing –Rate and depth Effort Breath Sounds Circulation –Pulses Skin Color, Temperature, Condition –Blood Pressure –Edema (Pitting/Sacral)

Focused Cardiac Exam Should include 3 components –Identify a chief complaint –History of the event and significant medical history –A physical examination

Chief Complaint Cardiovascular disease may cause a variety of symptoms Common complaints include –Chest pain/discomfort –Shoulder, arm, neck, back, or jaw pain –Shortness of breath –Syncope –Palpitations

Associated Complaints Diaphoresis Anxiety Feeling of impending doom Nausea/vomiting Dizziness Weakness Fatigue

History of Present Illness Chest Pain –Most common chief complaint –Use OPQRST Use clear questions Keep it simple

History of Present Illness Dyspnea –Main symptom of heart failure –Can be caused by other medical problems COPD Respiratory Infection Pulmonary Embolus Asthma

History of Present Illness Syncope –Caused by sudden decrease in oxygenated blood to the brain –Cardiac causes result from decrease in cardiac output –Most common cardiac cause is dysrhythmias Palpitations –Circumstances –Associated Symptoms

Past Medical History Is the patient taking any medications? Is the patient being treated for any other illnesses? Does the patient have any allergies? Does the patient have any risk factors for heart attack? Does the patient have implanted cardiac devices?

Physical Exam Should follow the Look-Listen-Feel approach –Look Skin color, JVD, Edema, Midsternal Scar –Listen Lung sounds –Feel Diaphoresis, Temperature, Pulse Palpate thorax and abdomen Vital Signs

Specific Cardiac Diseases Angina Pectoris Myocardial Infarction Congestive Heart Failure Cardiogenic Shock Thoracic and Abdominal Aortic Aneurysms Hypertension

Angina Pectoris Pathophysiology Symptom of myocardial ischemia “Choking pain in the chest” Most common cause is Atherosclerosis Caused by increased myocardial oxygen demand Stable vs. Unstable

Angina Pectoris Management Request ALS Intercept if not on scene Position of comfort Oxygen Medications –Aspirin –Nitroglycerin Prompt transport Prompt notification of receiving facility

Myocardial Infarction Caused by sudden, total blockage of coronary artery Death of myocardial tissue Sudden death usually because of dysrhythmias Can lead to heart failure Diagnosed using EKG findings, lab results

MI Management Request ALS intercept if not on scene Position of Comfort Oxygen Medications –Aspirin –Nitroglycerin Prompt transport Prompt notification of receiving facility

Nitroglycerin and Cardiac Compromise Most commonly prescribed medication for cardiac patients Derivative of explosive Medicinal nitroglycerin dilates blood vessels –Improves circulation to the heart tissue

Requirements for Assisting with Nitroglycerin Patient must have own prescription Prescription is current and not expired Patient has not taken medication for erectile dysfunction in the last 24 hours –Viagra, Cialis, Levitra –Note some systems have 48- or 72-hour limit Patient has systolic BP of at least 100 mmHg –Note some systems use different BP requirements

General Instructions for Assisting with Nitroglycerin Place one tablet or spray beneath tongue Allow to dissolve completely Instruct patient not to swallow tablets In general, if no relief –Reassess every 5 minutes –Repeat administration to maximum of 3 doses Follow local protocol

Reassess Reassess vital signs after each dose of nitroglycerin Ensure patient is sitting or lying down during administration Ensure BP remains  100 mmHg systolic Nitroglycerin may drop BP and cause lightheadedness or unresponsiveness

Change in BP or Mental Status If BP  100 or significant change in pulse or responsiveness Transport and continue with assessment and treatment en route

The Use of Aspirin Beneficial for treatment of patients with cardiac event Minimizes formation of blood clots within circulatory system Many EMS systems adding administration of aspirin to chest pain protocols Know your local protocols

Non-Cardiac Causes of Chest Pain Cholecystitis Hiatal Hernia Pancreatitis Pleural Irritation Pneumothorax Tumors

Differential Diagnosis Provocation Quality Radiation

Congestive Heart Failure Heart is unable to pump blood to meet metabolic needs Responsible for approx. 10,000 hospital admissions Most often caused by volume overload, pressure overload, loss of tissue or impaired contractility

Left Sided Heart Failure Left ventricle fails to pump forward Blood backs up into pulmonary circulation Characterized by: –Respiratory distress –PND –Abnormal lung sounds –JVD –Chest Pain

Right Sided Heart Failure Most often results for left sided failure Can be caused by chronic hypertension, COPD, PE, and Valve Disease Right ventricle fails as a forward pump Results in edema in dependent parts of the body

CHF Management Request ALS Intercept if not on scene Patient positioning High-flow oxygen –NRB Pulse oximetry Prompt transport

Summary There are many causes of chest pain BLS providers do have the means to treat patients with chest pain Remember that you must try to get ALS Follow your local protocols