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MVA with chest pain


EPmedic

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I'd get a very good history from the patient regarding previous cardiac history and chest pain questioning. While I'm doing that do a cervical spine immobilisation, 3-lead ECG to see underlying rhythm and get an IV in. Morphine for the pain as mentioned above. Once in the back of the ambulance do a 12-lead to see if there is anything cardiac. My first thought would be cardiac chest pain but I'd be looking for any signs of traumatic chest injury and ruling those out before treating for cardiac chest pain. I'd try and rule out:

- referring muscular chest pain from previous back injury

- pneumothorax

- fractured ribs and/or sternum

- flail chest

Then if my provisional diagnosis was cardiac chest pain I'd do aspirin and GTN. Some might say that if she does have traumatic injuries they could include internal bleeding which aspirin is not going to help, but I'd still go with it unless there was a strong index of suspicion there was an internal bleed. Also if she is compensating, the GTN could push her into decompensating shock. But again I'd have to have a strong suspicion there was a bleed.

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Dependant on the extent of impact as previously questioned (how deep of ravine, etc.) you have the initial cardiac symptoms to think about, the traumatic event and possible injuries sustained from this, and with the seat belt marks, this would indicate enough impact to cause any structural chest injury. Another concern would be cardiac contusion.

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Then if my provisional diagnosis was cardiac chest pain I'd do aspirin and GTN. Some might say that if she does have traumatic injuries they could include internal bleeding which aspirin is not going to help, but I'd still go with it unless there was a strong index of suspicion there was an internal bleed. Also if she is compensating, the GTN could push her into decompensating shock. But again I'd have to have a strong suspicion there was a bleed.

I have to assume that the 12 lead ruled out a Right Side MI. Nitro administration is a real risk if you are not sure.

And I am curious, why would you risk hypo-perfusion with your patient?

I think I would explore PTSD and emotional stress as a possible chest pain etiology as well.

Edited by DFIB
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I have to assume that the 12 lead ruled out a Right Side MI. Nitro administration is a real risk if you are not sure.

And I am curious, why would you risk hypo-perfusion with your patient?

I think I would explore PTSD and emotional stress as a possible chest pain etiology as well.

Absolutely. No GTN if the 12-lead did show that.

I don't think the risk of hypo-perfusion is that great unless (as stated above) there would be something that strongly indicates internal bleeding. Based on the vital signs we've been given I'm personally happy to provide cardiac chest pain treatment until anything cardiac is ruled out.

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