Advanced Medical Life Support

Chapter 6

Chest Pain

Introduction
Chest pain is one of the most common reasons why patients seek emergency medical care.

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Topics
Anatomy and Physiology
Initial Approach to Chest Pain

Differential Diagnosis and Management Priorities

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C ASE S TUDY
Situation
Call to a crowded office for c/o chest pain. 45 yo obese, African-American male seated on bench outside. Tie loosened, sl. sweaty, answering questions, states he is having some SOB. C/o aching mid chest, noticeable in his back. Started about an hr ago. Patient describes ache as unlike any he has experienced before; says it is worsening.
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C ASE S TUDY
Situation History
Discomfort began 1 hr ago, has been increasing. Patient has a high-stress job, smokes 1/2 ppd.

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Anatomy & Physiology

Any disorder that affects structures in or near the thorax can produce chest pain. In fact, so can some abdominal disorders.

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Thoracic Structures
Esophagus Clavicles Sternum Trachea Heart & major blood vessels

Costal cartilage
Lung

Pleura
Lung

Diaphragm
Ribs Pleural space
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Types of Chest Pain

Somatic -- Well localized in skin, parietal (parietal) pleura; described as SHARP. Example - Rib Injury
Visceral -- Various sources in chest & abdomen; described as HEAVY/BURNING/ACHING. Example - AMI
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Initial Approach to Chest Pain

The caregivers first priority is to determine whether or not the patients situation is life-threatening -- particularly in the case of

possible acute myocardial infarction (AMI).

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Causes of Chest Pain

Potentially life-threatening Non-life-threatening

AMI Unstable angina Aortic dissection Pulmonary embolism Espohageal rupture Cardiac tamponade Tension pneumothorax

Pericarditis Costochondritis Pleuritis Pneumonia Simple pneumothorax Esophageal spasm Esophageal reflux Acute cholecystitis Mitral valve prolapse
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Assessment Priorities
Initial Assessment Focused History & Physical Exam

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Initial Assessment
Immediate determinations:
Any compromise of ABCs? Immediate life-threatening conditions? Cardiac cause for pain?
React quickly! Protect airway Treat for rhythm disturbances, hypoperfusion
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Focused History & Physical

Once ABCs addressed, conduct a more thorough H & P to determine cause of complaint.

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Focused History
Past Medical History
SAMPLE Questions
S igns & symptoms A llergies M edications P ast medical history L ast oral intake E vents prior to illness
History should focus on characterizing the complaint.

Intensity & quality of pain may be unreliable in pinpointing the source of trouble. Determine presence of any risk factors re/ hidden medical conditions. 6-14

Focused History (continued)

Characterizing the Complaint

OPQRST Questions
O nset P alliation/provocation Q uality R adiation/location S everity T ime

Was onset abrupt or gradual?

Onset of pain of an AMI or aortic dissection is usually abrupt. Onset of pain of pericarditis or pneumonia is gradual. Explore circumstances leading up to complaint.
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Focused History
Characterizing the Complaint (continued)

OPQRST Questions
O nset P alliation/provocation Q uality R adiation/location S everity T ime

What relieves the pain? What makes it worse?

Nitroglycerin? Antacids? (Unreliable without further data.) Deep inspiration?

Firm palpation?
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Focused History
Characterizing the Complaint (continued)

OPQRST Questions
O nset P alliation/provocation Q uality R adiation/location S everity T ime

How does patient describe the discomfort?

Patients who fear AMI may deny symptoms.

Note & relay patients descriptive terms.

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Focused History
Characterizing the Complaint (continued)

OPQRST Questions
O nset P alliation/provocation Q uality R adiation/location S everity T ime

Where is the discomfort? Where does it radiate?

Stay aware of classical patterns of pain (AMI, dissecting aorta, etc.) Concentrate on what the patient actually describes.
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Focused History
Characterizing the Complaint (continued)

OPQRST Questions
O nset P alliation/provocation Q uality R adiation/location S everity T ime

How severe is the pain?

Use 10-scale, if helpful (but dont insist). Be aware of patients words, gestures & appearance.

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Focused History
Characterizing the Complaint (continued)

OPQRST Questions
O nset P alliation/provocation Q uality R adiation/location S everity T ime

When did the discomfort first come on?

Listen to what patient says.

Consider possibility that patient cannot pinpoint time of onset (avoid badgering the patient).
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Focused History (continued)

Associated Symptoms

Shortness of breath/coughing Nausea, vomiting Diaphoresis Hemoptysis Syncope Rashes

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Focused History (continued)

Pre-existing Medical Conditions

Predisposing physical factors? Known risk factors? Family history? Recent surgery/stasis? Recent travel? Pregnancy history/status now?
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Focused Physical Exam

Appearance (Note position! Be alert for
anxiety, dyspnea, diaphoresis, discomfort)

Skin vitals (color, temp, condition) Vital signs (pulse, respirations, BP, pulse-ox) Lung sounds (note crackles, friction rub,
decreased breath sounds)

Cardiac (murmurs, rubs, clicks, dysrhythmias)

Abdominal & Chest Wall (note tenderness)

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Management Priorities
Chest pain is a serious finding that automatically warrants: Timely treatment Prompt transport

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General Management Priorities For Patients with Chest Pain

Administer O2. Monitor ECG. Monitor O2 saturation.
(watch for clinical evidence of hypoxia)

Establish IV access.
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Acute Myocardial Infarction

Typical Features
History
BP Diabetes Smoking Obesity Cholesterol Family Hx of heart disease Prior cardiac disease

Type of Pain Symptoms

Midsternal/ epigastric Burning Crushing Pressure Squeezing May radiate to arms, neck, jaw 1 in 4 c/o sharp or stabbing pain Older pts, diabetics may have no pain Sweating SOB Nausea Dizziness

Rx
O2 Pulse ox ECG Drugs: ASA Ntg MS Xmit 12-lead

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Signs, Symptoms of AMI

Midsternal or epigastric discomfort crushing pressure-like squeezing burning (?) not much relief from Ntg Radiation to arms, neck, jaw Anxiety, nausea, dizziness, dyspnea, diaphoresis

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Levines Sign
Fist clenched over sternum suggests chest pain of cardiac etiology

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Unstable Angina
Typical Features
History
Symptoms occur more often, w/ less exertion, at rest, or are new

Type of Pain Symptoms

Similar in character Promptly to pain of AMI relieved by rest or Ntg Lasts 5-15 min. (Many variances)

Rx
O2 Pulse ox ECG Drugs: ASA Ntg MS Xmit 12-lead

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Aortic Dissection
Typical Features
History
Hypertensive males aged 40-70 years Marfans syndrome Ehler-Danlos syndrome

Type of Pain Symptoms

Tearing Cutting Ripping Radiating to back, flank, arm Most intense at onset Vary w/location May be stroke-like Neurologic abnormalities Loss of upper extrem. pulses Muffled HS Hypotension Diastolic murmur

Rx
General supportive care Difficult to disting. from AMI in field setting Transport promptly but gently.

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Pulmonary Embolism
Typical Features
History Type of Pain Symptoms
Sharp Pleuritic

Rx

Immobility Pregnancy Oral Estrogen Cancer Smoking 1 in 5 pts have no risk factors

Supportive care Dyspnea Prompt transport Tachypnea Tachycardia Hypoxia possible Hypotension, rarely Warm, tender venous cord in lower extr. Crackles or rales Pleural rub
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Esophageal Disruption
Typical Features
History Type of Pain Symptoms
Dysphagia Hemoptysis Fever Tachycardia Tachypnea Hypotension Pleural rub

Rx
Aggressive fluid resuscitation ECG Prompt transport

Forceful Sharp, steady vomiting or Felt in anterior coughing chest, back, Recent N-G tube epigastrium or endoscopy Radiation to neck

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Cardiac Tamponade
Typical Features
History
Pericarditis Malignant pericardial effusions

Type of Pain Symptoms

May be pain w/ inflammatory process No pain w/ effusions Similar to pain of pericarditis

Rx

Distended Supportive care neck veins, Fluid boluses hypotension, Prompt transport muffled HS Dyspnea Tachycardia Tachypnea Narrowing pulse pressure Pulsus paradoxus
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Signs of Cardiac Tamponade

Distended neck veins

Muffled heart sounds

Hypotension, narrowed pulse pressure

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Tension Pneumothorax
Typical Features
History
Weakening of lung tissue (i.e., Cancer, infection) COPD PPV therapy Exertion or coughing

Type of Pain Symptoms

Sudden Sharp Pleuritic

Rx

Shallow, tachypneic High-flow O2 respirations Decompress Pain on deep affected lung inspiration using largeNeck vein distention bore needle Severe progressive respiratory distress Tracheal deviation breath sounds Hypotension
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Signs of Tension Pneumothorax

Pleuritic, inspiratory pain sudden onset poss. after exertion or coughing Neck vein distention Tracheal deviation

Severe, obvious respiratory distress rapid, shallow breathing worsens with time

breath sounds (on affected side)

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Needle Decompression
Insert a large-bore needle through the chest wall on the affected side: above third rib midclavicular line

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Pericarditis
Typical Features
History Type of Pain Symptoms Rx
Supportive care (NSAIDS: ibuprofen) Cancer Gradual onset Friction rub Renal failure Steady ECG may reveal Other inflamma- Burning S-T changes tory conditions similar to AMI Retrosternal (may radiate to back, neck, jaw, scapula) Worse on inspiration & when recumbent Longer duration than myocardial pain

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ECG Findings with Pericarditis

ECG findings may be similar to those seen with AMI.

S-T Elevation S-T Depression

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Costochondritis
Typical Features
History
Non-specific

Type of Pain Symptoms

Gradual onset Sharp Worsened by chest wall movement (i.e., lifting arms, firm palpation, deep respirations)

Rx

Localized chest Heat wall tenderness Cool compresses Possible fever (NSAIDS)

Note: Diagnose by exclusion.

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Pleurodynia
Typical Features
History
Non-specific

Type of Pain Symptoms

Sharp Pleuritic Few positive findings Pleural rub possible

Rx
Heat Cool compresses (NSAIDS)

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Gastrointestinal Disorders
Typical Features
History Type of Pain Symptoms Rx
Peptic Ulcer Cholecystitis Esophagitis Esophageal spasm Gastroesophageal reflux
Retrosternal Supportive care Acidic taste burning similar Pain on palpation to AMI of epigastrium, Radiates throat upper abdomen Worse at night, when recumbent Longer duration than myocardial pain

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Mitral Valve Prolapse

Typical Features
History
Non-specific

Type of Pain Symptoms

Probably none

Rx

Dizziness Supportive care Dyspnea Palpitations Syncope Systolic murmurs, clicks possible Dysrhythmias Most asymptomatic

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Treatment Pathway for Chest Pain

Scene Size-up Initial Assessment Airway support, O2, treat dysrhythmias, treat for shock Chest pain present? Assume serious underlying condition, possible AMI Focused History & Physical Exam General supportive measures: O2 IV, ECG, pulse oximetry Preliminary impression established? AMI: Supportive care; fluid bolus; Ntg, ASA, MS; transmit 12-lead ECG, Thrombolytics Unstable angina: (difficult to distinguish from AMI) Supportive care; treat as for AMI

(continued)

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Chest Pain Treatment Pathway (continued)

Aortic Dissection (difficult to distinguishfrom AMI): Supportive care; treat as for AMI Esophageal rupture: Supportive care; aggressive fluids Tension Pneumothorax: Supportive care; decompress affected lung Costochondritis: Supportive care Gastrointestinal disorders: Supportive care Pulmonary embolism: Supportive care; fluid bolus if hypotensive Cardiac Tamponade: Supportive care; fluid bolus; pericardiocentesis Pericarditis: Supportive care Pleurisy: Supportive care Mitral valve prolapse: Supportive care

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C A S E S T U D Y F O L L O W-U P
Situation
Call to a crowded office for c/o chest pain. 45 yo obese, African-American male seated on bench outside. Tie loosened, sl. sweaty, answering questions, states he is having some SOB. C/o aching mid chest, noticeable in his back. Started about an hr ago. Patient describes ache as unlike any he has experienced before; says it is worsening.
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C A S E S T U D Y F O L L O W-U P
Situation History
Patient has a high-pressure job, smokes ~1/2 ppd. Possible ulcer in the past.

Only medication: has been taking Procardia qd x 15 years, for hypertension.

Pts father died of a heart attack in his early 50s.

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C A S E S T U D Y F O L L O W-U P
Findings & Treatment
Vitals: P=60, regular & bounding; R=18 & unlabored; BP=170/100. PE remarkable only for obesity, diaphoresis & some anxiety. O2 via nasal cannula @ 4 lpm, IV of NS, ECG (reveals RSR). Because AMI suspected, pt given 325mg aspirin & 0.4 mg Ntg. Twelve-lead ECG transmitted. Transport. Enroute, admin. 2 more Ntg tablets some relief of pain. Vitals unchanged.
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C A S E S T U D Y F O L L O W-U P
Findings & Treatment Response to Care
On arrival, ED staff confirms ECG evidence of inferior AMI. Patient undergoes successful angioplasty for occluded right coronary artery, has an uneventful recovery.

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