…time is myocardium!

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Cardiovascular disease (CVD) claimed over 1 million lives in 2004.
CVD has been the leading cause of death for Americans since 1900.
Sudden cardiac death accounts for over 40% of these deaths.
The majority of our 911 responses are for chest pain.

Smoking
High blood pressure
Elevated cholesterol levels
Elevated blood glucose levels
Diet
Lack of exercise
Stress

Uncontrollable Risk Factors
Age
Family history
Race
Sex

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Red blood cells:
• Carries oxygen to tissues and cells
• Removes CO2 and waste
• White blood cells:
• Fight infection
Platelets:
• Helps blood clot

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• Chest pain results from ischemia.
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Ischemic heart disease involves decreased blood flow to the heart.
• If blood flow is not restored, the tissue dies (infarct).
Injury leads to inadequate heart function and death.

…you are dispatched to a 67 year- old male c/o 9/10 “crushing” chest pressure that radiates to his jaw. He is also complaining of shortness of breath and nausea, with no previous cardiac history…

…w

Chest Pain Pathophysiology
• Mediastinum:
• Angina: stable or unstable
• AMI
• Esophagitis, esophageal rupture
• Pericarditis
• Mediastinal air
• Thoracic dissection
• Mitral valve prolapse

Chest Pain Pathophysiology
• Chest Wall:
• Traumatic contusion/ tamponade
• Cysts and infections
• Rib cartilage inflammation
• Shingles (Herpes Zoster)
• Muscle strain, overuse syndromes

Chest Pain Pathophysiology
• Lungs and pleura:
• Pleurisy
• Pneumonia
• Pneumothorax, hemothorax
• Pulmonary embolus
• Asthma, bronchitis, URI

Chest Pain Pathophysiology
• Abdomen:
• Gallbladder (cholecystitis, stones)
• Stomach (gastritis, GERD, perforated peptic ulcer)
• Pancreas (pancreatitis)
• Esophagitis, perforation

• Psychogenic:
• Stress
• Hyperventilation
• Anxiety and panic attacks

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• Pressure, fullness, heaviness, squeezing pain in center of chest with radiation
Diaphoresis
Nausea
Shortness of breath
Weakness

• Diaphoresis 78%
• Chest pain 64%
• Nausea 52%
• Shortness of breath 47%
• No signs/symptoms 25%
N Engl J Med 1984;311:1144-7

• Common in the elderly, diabetics, and females:
• Unusual fatigue
• Sudden onset of unusual shortness of breath
• Nausea, dizziness
• Belching, burping, indigestion
• Palpitations, new dysrhythmia
• Pain only in jaw, neck, back, arm

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• Chest pain caused when heart tissues do not get enough oxygen for a brief period of time.
Typically crushing or squeezing.
Onset with the 3E’s.
• Usually resolves with rest or meds.
• May be difficult to diagnose from AMI

Acute Coronary Syndrome
Used to describe the range of conditions from unstable angina to AMI.
Signs and symptoms usually caused by acute myocardial ischemia.

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Shortness of breath
Signs of inadequate perfusion
Chest pain, pressure, or discomfort
(with or without radiation to back, neck, jaw, arm, wrists)
Nausea
Weakness/syncope
Dysrhythmias

Usually caused by the same mechanism as angina only with resulting tissue death.
Time is myocardium:
Consequences can be serious:
Congestive heart failure
Cardiogenic shock
Sudden death

Heart lacks power to force blood through the circulatory system.
Brought on when 40% of left ventricle is infarcted.
Onset may be immediate or not apparent for 24 hours.

• Altered LOC
• Rapid, shallow breathing
• Restlessness and anxiousness
• Pale, cool skin
• Tachycardia/dysrhythmia
• Hypotension

Occurs when the ventricles are damaged.
Heart tries to compensate with increased heart rate.
Enlarged, ineffective left ventricle
Fluid builds up into lungs or body as
“pump” fails.

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• Fatigue
Cough with pink, frothy sputum
Dypsnea, tachypnea
Pulmonary edema
Agitation and confusion
Hypertension
Pedal edema, ascities

• Sudden and severe chest or upper back discomfort. “Pain shoots to the shoulder blades.”
• Anxiety
• Diaphoresis
• Nausea

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• Trauma induced, filling of the pericardial sac with blood.
Signs of shock
JVD
Decrease pulse pressures

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Usually underlying alcohol abuse.
• Shock signs.
Coughing up bright red blood.

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Inflammation of the pericardium caused by infection.
Usually presents as sharp discomfort.
Changes with breathing and movement.

BSI/Scene Safety
Initial Assessment (Sick/Not Sick)
Focused Exam
Detailed Exam
Assessment
Treatment and Plan

Initial Assessment
60second clinical picture to determine if
Sick or Not Sick (Oxygen)
Based upon your initial impression:
– Body position
– skin signs and color
– respiratory rate and effort
– mental status
– pulse rate and character
Correct immediate life threats!

Your subjective findings are based upon what the patient or historian tells you:
Patient Age
Sex
Chief Complaint

Focused Exam (S)
SAMPLE History
S igns/ S ymptoms (associated with cardiac chest pain):
– Diaphoresis (78%)
– Shortness of Breath (47%)
– Pain/discomfort (64%)
– Nausea/vomiting (52%)
– No signs or symptoms (25%)
N Eng Journal Med 1984;311:11444-7

Focused Exam (S)
O nset –
“When and at what time did it start”
P rovocation –
“Does anything make it better or worse?”
“Does it change with position, palpitation, inspiration?”
Q uality –
“Describe the pain/discomfort in your own words”

Focused Exam (S)
R egion/ R adiation –
“Where does it start?”
“Does it radiate anywhere?”
S everity –
“On a scale of 1 to 10, what was the pain/discomfort at onset?”
“What is the pain/discomfort at now?’
T ime –
“When did this episode start?”
“How long has it been going on?”

Focused Exam (S)
A llergies
M edications –
Cardiac meds = cardiac problems.
Ask about OTC meds, natural supplements, vitamins?
P ast Medical History –
“Do you have any cardiac history?”
“Risk factors such as smoking, diabetes, HTN, weight/diet?””

Focused Exam (S)
L ast Oral Intake
E vents Leading to Call –
“What were you doing when this event started?”
Think activity induce vs. non activity

…they will tell you exactly what is wrong!

Focused Exam (O)
Objective findings from your physical exam of the patient.
Look for evidence of trauma/injury
Evaluate:
– Level of consciousness
– Skin color and temperature
– Respiratory rate and effort
– Pupillary reaction
– Pulse rate
– Blood pressure (bilateral for chest pain!)

Focused Exam (O)
Listen to breath sounds
Palpate chest
Palpate abdomen
Check pedal pulses
BGL if diabetic with DLOC
SpO2 after BP, confirm with pulses, RA & after administration of O2
Rhythm strip?

Focused Exam (O)
Based upon your clinical findings
Observe the patient while they are talking with you, note any distress/discomfort (Levine sign)
Watch for acute clinical signs: jugular vein distension, tracheal deviation, paradoxial chest movement.

Detailed Exam (O)
Complete and thorough neck, head to toe examination with non-critical patients if needed or time permits.
Elicit further information and necessary interventions.
Key in on critical findings!

This is your best guess (or rule out) as to what is going on with the patient.
It is based upon YOUR Subjective and
Objective findings and should help you develop and implement your Plan for patient care.

Medics?
ABC’s/Monitor vitals
Patient in position of comfort.
Oxygen via ?
Assist with medications.
Maintain body temperature.
Calm and reassure.
Minimize patient movement.
Rapid transport!

• Coronary artery bypass graft (CABG) and other open heart surgeries
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• Percutaneous transluminal coronary angioplasty (PTCA)
Automatic implantable cardiac defibrillators (ACID)
• Pacemakers