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 200-250 ml each
minute
• Left coronary artery
carries 85%
– LAD
– Circumflex
• Right coronary carries
remaining volume
Conduction System
• Cardiac muscle is unique
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Automaticity
Excitability
Conductivity
Contractility
Conduction System
• Sinoatrial node (SA)
– Primary pacemaker
– Inherent rate 60-100
• Atrioventricular
Junction
– Inherent rate 40-60
– 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
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Chest pain/discomfort
Shoulder, arm, neck, back, or jaw pain
Shortness of breath
Syncope
Palpitations
Associated Complaints
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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
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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
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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
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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
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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
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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:
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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