Chest Pain and the BLS Provider

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Chest Pain and the BLS Provider

• By
• Daniel B. Green II, NREMT-P, CCP

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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

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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

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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

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Prevention Strategies

• Educational Programs
• Nutrition
• Smoking Cessation
• Recognition of Symptoms and Prompt Intervention

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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

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Cardiac Anatomy and Physiology

• Epicardium
• Outermost layer (Visceral Pericardium)
• Myocardium
• Thick middle layer
• Endocardium
• Smooth, inner layer of connective tissue

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Chambers of the Heart

• Atria
• Superior chambers
• Less muscular
• Ventricles
• Inferior chambers
• More muscular
• Left is 3 times thicker than right

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Heart Valves

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

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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
• Lets trace a drop of blood through the body

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Coronary Arteries

• Carry 200-250 ml each minute
• Left coronary artery carries 85
• LAD
• Circumflex
• Right coronary carries remaining volume

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Conduction System

• Cardiac muscle is unique
• Automaticity
• Excitability
• Conductivity
• Contractility

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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

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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)

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Focused Cardiac Exam

• Should include 3 components
• Identify a chief complaint
• History of the event and significant medical
  history
• A physical examination

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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

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Associated Complaints

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

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History of Present Illness

• Chest Pain
• Most common chief complaint
• Use OPQRST
• Use clear questions
• Keep it simple

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History of Present Illness

• Dyspnea
• Main symptom of heart failure
• Can be caused by other medical problems
• COPD
• Respiratory Infection
• Pulmonary Embolus
• Asthma

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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

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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?

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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

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Specific Cardiac Diseases

• Angina Pectoris
• Myocardial Infarction
• Congestive Heart Failure
• Cardiogenic Shock
• Thoracic and Abdominal Aortic Aneurysms
• Hypertension

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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

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Angina Pectoris Management

• Request ALS Intercept if not on scene
• Position of comfort
• Oxygen
• Medications
• Aspirin
• Nitroglycerin
• Prompt transport
• Prompt notification of receiving facility

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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

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MI Management

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

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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

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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

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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

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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

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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

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Non-Cardiac Causes of Chest Pain

• Cholecystitis
• Hiatal Hernia
• Pancreatitis
• Pleural Irritation
• Pneumothorax
• Tumors

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Differential Diagnosis

• Provocation
• Quality
• Radiation

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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

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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

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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

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CHF Management

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

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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