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Cardiac Chest Pain?

20 posts in this topic

Posted · Report post

Dispatch: Caller states that his father is experiencing chest pain.

 

You arrive to find a 30 year old male meeting you at the door saying his father is having terrible chest pain please hurry!

 

Your patient is a 54 year old male patient. You find your patient sitting in his recliner holding his chest, the patient appears anxious. He says he has never had this chest pain before but needs you do something, he thinks he is having a heart attack. Who's on first?

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Posted · Report post

Has he ever had pain like this before? 

Does the pain go anywhere apart from in his chest?

What type of pain is it? sharp? stabbing? cramping? 

How bad is the pain? 

 

Does anything make the pain better or worse?

What is his past medical history like?

Does he have any family history of heart disease?

When did he last eat?

 

Ix - obs and 12 lead ECG including V4R, right sided or posterior leads as appropriate?

Does physical exam reveal anything? lung sounds? heart sounds? JVP?

 

PDx - myocardial ischaemia until proven otherwise 

DDx - MSK pain, spontaneous pneumothorax, trauma, PE, chest infection, pneumomediastinum, AAA, acute ventricular aneurysm, acute valve rupture, pericarditis/myocarditis, epigastric pain, GERD

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Posted (edited) · Report post

Pt HX , eval , vitals, orthostatic BP, quick 12 lead while stretcher/ stair chair is being brought in

325 mg ASA if no contraindications , O2, IV access, NTG if indicated,& not taking the magic blue boner pill,  put his butt on the stretcher, get in the office and start heading towards definitive care while doing all the above. We have a thirty minute ride to small hospital and hour plus to cath lab if determined by diagnostic review and evaluation.

Today with the weather might take a couple hours due to whiteout conditions just to get to the local hospital.

 

If your in the big city with a cardiac center on almost every street corner. stay in the house and play with all the toys as your transport time is only three minutes.

Edited by island emt

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Posted · Report post

pericardit......awww screw it.

3 people like this

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Posted · Report post

I actually got to see a case of pericarditus the other day trevor. Wasn't my patient , but the ER doc had us all look at the 12 lead to see if we picked up on it..

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Posted · Report post

I think you told me about that in a different thread.

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Posted · Report post

This was just this past tuesday. I do have a copy of the twelve lead at the station . I'll scan it and see if I can post it. 

Whenever we get dug out. :-}

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Posted · Report post

Erectile dysfunction pills are not a contraindication to GTN here, just a warning that it is prudent to give a reduced dose i.e. 0.4 mg SL instead of the usual 0.8 mg

 

If there was no very strong evidence as to an alternate, non cardiac cause I would give him aspirin.

 

Entonox +/- morphine as required for analgesia.  

 

Serial 12 leads 

 

Transport to the hospital 

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Posted · Report post

Has he ever had pain like this before? 

Does the pain go anywhere apart from in his chest?

What type of pain is it? sharp? stabbing? cramping? 

How bad is the pain? 

He has never had this type of pain before.

It says it does radiate a little on each side, but is substernal.

He said it feels like a strong pressure and that he can't breathe.

He describes the pain as a 8/10

Does anything make the pain better or worse?

What is his past medical history like?

Does he have any family history of heart disease?

When did he last eat?

 

Ix - obs and 12 lead ECG including V4R, right sided or posterior leads as appropriate?

Does physical exam reveal anything? lung sounds? heart sounds? JVP?

 

PDx - myocardial ischaemia until proven otherwise 

DDx - MSK pain, spontaneous pneumothorax, trauma, PE, chest infection, pneumomediastinum, AAA, acute ventricular aneurysm, acute valve rupture, pericarditis/myocarditis, epigastric pain, GERD

He hasn't done anything he called as soon as it started really hurting, He said it started a couple of days ago, but has gotten worse over the time period. He had a gravy biscuit for breakfast (It's now 11:30.) His father had one heart attack. 12 lead reveals no ST elevation/depression or T wave depression, Posterior and Right sided are performed with the same result.

 

Lung sounds are clear, heart sounds are noted with S1 and S2 with no gallop or murmurs. No JVD.

 

He states that he has had heartburn before, but this is not heartburn, this is presenting differently.

 

What else would you like to do for assessment?

 

 

Pt HX , eval , vitals, orthostatic BP, quick 12 lead while stretcher/ stair chair is being brought in

325 mg ASA if no contraindications , O2, IV access, NTG if indicated,& not taking the magic blue boner pill,  put his butt on the stretcher, get in the office and start heading towards definitive care while doing all the above. We have a thirty minute ride to small hospital and hour plus to cath lab if determined by diagnostic review and evaluation.

Today with the weather might take a couple hours due to whiteout conditions just to get to the local hospital.

 

If your in the big city with a cardiac center on almost every street corner. stay in the house and play with all the toys as your transport time is only three minutes.

 

You have IV access with blood drawn (if per your protocols), 12 lead performed without ST or T wave depression or elevation. Vitals remain stable throughout the orthostatics. VItals are as follows: B/P= 182/110 HR= 120, SpO2= 98 RA, ETCO2= 40. No contraindications to ASA or NTG. Both given without any relief, but now he has a headache.

 

What do you want to do next now that your transporting?

 

pericardit......awww screw it.

 

Quite possibly, continue assessing.

 

Erectile dysfunction pills are not a contraindication to GTN here, just a warning that it is prudent to give a reduced dose i.e. 0.4 mg SL instead of the usual 0.8 mg

 

If there was no very strong evidence as to an alternate, non cardiac cause I would give him aspirin.

 

Entonox +/- morphine as required for analgesia.  

 

Serial 12 leads 

 

Transport to the hospital 

 

As listed above, 12 leads show no abnormalities. You have administered Morphine and the patient states that his pain has decreased from an 8/10 to a 6/10. What's next?

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Posted · Report post

I think you've done all you can in the back of the ambulance.  You have a non-diagnostic for MI 12 lead, the MS has dropped his pain from 8 to a 6.  

 

What else can you do?

 

You have also drawn blood and the lab will draw it unless they are wussies and say  "it's heeeeeeeeeeeeeeeeeeeeeemmmmmmmoooooooooooooooooolllllllllyyyyyyyyyyyyyyyyyyyyyyyyyyyyyzzzzzzzzzzzzzzzzzzzzzeeeedddddddddddd"  which many often do with field draws.  You know we can't draw blood to save our asses.  Plus they come back with CLIA regs saying that if their staff didn't draw the blood it doesn't count.  waa waa waa.

 

So what else can we do on the amblulance??   

 

Give him more morphine and see if that helps, Do you have a nitro drip?  You could give that if his pressure allows.  

 

But other than that< I'm going to continue transport and drop him off, do my report and return to my reclining passenger seat to await my next call or maybe go get a large coke zero and a snack.  It's only 9:49am where I'm at.  

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