Sorting It Out: Chest Pain, Cardiac Arrest and SOB

Sorting It Out: Chest Pain, Cardiac Arrest and SOBMichael Lohmeier, MDJune 24, 2014

Sorting It All OutBefore I beginThank You for this opportunityA Little About MeMichael LohmeierAssistant Professor of Medicine, Emergency MedMedical Director; Madison Fire, FitchRona EMS, Middleton EMS, Dane County EMS, UW PD First RespondersMedical Director, University of Wisconsin EECDirector, EMS Rotation for Residents

Sorting It All OutPer the Wisconsin EMS Association Website598,416 calls for EMS in 201115% increase from 201040% of calls are responded to by 10 services in the stateIn 1992, only 9% of Wisconsin ambulance services operated at the Paramedic levelToday, 32% of services are licensed at this level68% of services are trained and authorized to start IVs and administer 8 or more medications~20% of calls require the administration of one or more meds~10% are true life threatening situationsThats 59,000 patients per year!

https://www.wisconsinems.com/ems-for-the-general-public/wisconsin-ems-statistics/

Sorting It All OutQuotableThe only man who never makes a mistake is the man who never does anything.

-Theodore Roosevelt

Sorting It All OutWhy should you care?Chest Pain is one of the most common reasons for activating 9-1-1Unofficial Dane County DataEmergency Department dataNot everything that presents with chest pain is cardiacTime lost is muscle lostEMS is triaged to cardiac cath labs in many parts of the stateThe public expects you to get it rightMisdiagnosing an MI can be deadly!Aortic dissectionPericarditis

http://www.cdc.gov/nchs/fastats/emergency-department.htmhttp://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2010_ed_web_tables.pdf

Dane County Data Jan 1, 2014 June 23, 2014 there were 12,389 calls. Chest Pain was 6.4%, Cardiac Arrest was 1.23%, Asthma and COPD was 1.58%Data is not perfect; 7.18% of calls were for Other and 8.59% were for pain.

129.8 million ED visits in 2010. For the non-traumatic visits, chest pain was #2 and shortness of breath was #65Sorting It All OutChest Pain, Shortness of Breath and Cardiac Arrest can be on a spectrum of cardiac ischemia or completely unrelated!Approximately 129.8 million people visit the ED in 20105.4% of visits for chest pain2.7% of visits for shortness of breath2.7% of visits for coughCritical diagnoses causing either varies widelyACS, aortic dissection, pulmonary embolism, tension pneumothorax, pericardial tamponade, esophageal rupture

http://www.cdc.gov/nchs/fastats/emergency-department.htm Sorting It All OutDifferentialsChest PainAcute MIUnstable AnginaPEAortic DissectionPneumothoraxCardiac TamponadeEsophageal RupturePericarditis

Shortness of BreathAsthma and COPDPneumoniaPneumothoraxPulmonary EmbolismTraumaAcute Coronary SyndromeEndocrine (DKA, metabolic acidosis)Hematologic (anemia)Toxins (Salicylate overdose)Ascites

Sorting It All OutDifferentialsChest PainAcute MIUnstable AnginaPEAortic DissectionPneumothoraxCardiac TamponadeEsophageal RupturePericarditis

Shortness of BreathAsthma and COPDPneumoniaPneumothoraxPulmonary EmbolismTraumaAcute Coronary SyndromeEndocrine (DKA, metabolic acidosis)Hematologic (anemia)Toxins (Salicylate overdose)Ascites

Sorting It All OutWhat causes chest pain?Afferent nerve fibers carry signals from the body to the brain Fibers from the heart, lungs, great vessels and esophagus enter the same thoracic dorsal gangliaThese ganglia overlap the 3 segments above and belowLocation and quality of the pain are indistinct to the patientCan be from the jaw to the epigastriumSome somatic afferent fibers synapse in the same dorsal root ganglia and can confuse the CNSGives referred pain

Sorting It All Out

What causes shortness of breath?dyspnea is the term used for the sensation of breathlessness and the patients reactionNeither the clinical severity nor the patients perception correlates well with the seriousness of underlying pathologyThe actual mechanisms for dyspnea are unknownImbalance between the respiratory center in the medulla oblongata and the chemoreceptors near the carotid bodiesIncreased work of breathingIncreased respiratory drive

Sorting It All OutJust to recapChest Pain is indistinct to the patient, source may be unclear on examDyspnea is subjective, may be related to a physical, metabolic or psychiatric conditionDifferential is enormous, from non-emergent to the most critical diagnoses in medicineAwesome.http://healthinessbox.files.wordpress.com/2012/09/chest_pain.jpg

Sorting It All OutWhat are the life threats, and does this patient need an intervention immediately?There is no simple algorithmKeep your approach organized and systematicKeys to narrow down your differential will be in the history, physical exam and EKG in ~90% of patientsMajority of diagnosis is going to come from the historyIf theyre already in cardiac arrest, run the ACLS algorithmsDesigned to treat the underlying etiologiy of arrestWe want to prevent that from happening!

Sorting It All OutHistoryDont forget your O-P-Q-R-S-T!OnsetWhat were you doing when you started having pain?Provocation or palliationWhat makes the pain better or worse?QualityCan you describe the pain? Sharp, dull, achy, stabbing, burning?Region and RadiationWhere is the pain, and does it go anywhere?SeverityOn a scale of 0-10 with zero being no pain, how bad does this hurt?TimingHow long has this been going on and how has it changed since the beginning?http://www.emtresource.com/resources/acronyms/opqrst/

Activity at onset may be helpful. Pain with exertion suggests ischemic coronary syndrome, while progressive pain at rest suggests MI. Sudden onset pain may be PE, PTX or aortic dissection. Pain after eating may be a GI sourcePain that worsens with with exertion and improves with rest is more likely related to coronary ischemia. Pain related to meals may be GI related. Pain worse with breathing is more often pulmonary, pericardial and MSK causesSqueezing, crushing or pressure are more indicative of a cardiac ischemia. Tearing pain may be an aortic dissection. Sharp and stabbing pain is more common in pulmonary and MSK causes. Burning and indigestion may indicate GI sourcePain that is localized to a small area is more likely somatic vs. visceral. Pain in the periphery of the chest more likely pulmonary. Low chest or upper epigastric may be GI or cardiac in nature. Radiation to the back is concerning for dissection, pancreatitis, posterior GI ulcers. Radiation to the arms, neck of jaw more commonly from cardiac causeSeverity of pain should be documented at onset, peak, present and after interventionsPain that lasts a few seconds or minutes is typically not cardiac in nature. Exertional pain that abates with rest may be cardiac ischemia. Severe, maximum pain at onset is concerning for dissection. Mile pain that lasts over days is less likely to be serious than the fluctuating or stuttering chest pain.

13Sorting It All OutHistoryA history of prior pain and the diagnosis can be quite helpful in narrowing down your differentialBut beware the biggest barrier to making the correct diagnosis isThe previous diagnosis!!Associated symptoms may be helpful as wellDiaphoresis should suggest a serious or visceral causeHemoptysis is a classic PE sign that is seen in about 1/5 the timeNausea and Vomiting can be GI or cardiac in natureRisk factors are important to consider when evaluating a patientGood to know from a population basis, not as helpful with the individual

Sorting It All OutHelpful Physical Exam findingsAppearanceAcute Respiratory DistressDiaphoresisVital SignsHypotensionTachycardiaBradycardiaHypertensionFeverHypoxemia

Acute respiratory distress PE, Tension Pneumo, Acute MIDiaphoresis PTX, Acute MI, Aortic Dissection, Coronary Ischemia, PE, Esophageal Rupture, Unstable Angina, Cholecystitis, Perforated Peptic UlcerHypotension Tension Pneumothorax, PE, Acute MI, Aortic Dissection (late), Coronary Ischemia, Esophageal Rupture, Pericarditis, MyocarditisTachycardia Acute MI, PE, Aortic Dissection, Coronary Ischemia, Tension Pneumothorax, Esophageal Rupture, Coronary Spasm, Pericarditis, Myocarditis, Mediastinitis, Cholecystitis,Bradycardia Esophageal Tear (Mallory-Weiss), Acute MI, Unstable AnginaHypertension Acute MI, Coronary Ischemia, Aortic Dissection (early)Fever PE, Esophageal Rupture, Pericarditis, Myocarditis, Mediastinitis, Cholecystitis,Hypoxemia PE, Tension Pneumothorax, Pneumothorax

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Sorting It All OutHelpful Physical Exam findingsCardiovascular ExamAsymmetric Upper Extremity Blood PressuresNarrow Pulse PressureNew MurmurS3/S4 GallopPericardial RubAudible Systolic Crunch (Hammans Sign)JVDPulmonary ExamUnilateral Diminished Breath SoundsPleural RubSubcutaneous EmphysemaRales

Asymmetric Pressures Aortic DissectionNarrow Pulse Pressure Pericarditis (with effusion)New Murmur Acute MI, Aortic Dissection, Coronary IschemiaS3/S4 Gallop Acute MI, Coronary IschemiaPericardial Rub PericarditisAudible Crunch Esophageal Rupture, Mediastinitis,JVD Acute MI, Coronary ischemia, Tension Pneumothorax, PE, Pericarditis

Unilateral Diminished BS Tension Pneumothorax, PneumothoraxPleural Rub PESubcutaneous Emphysema Tension Pneumothorax, Esophageal Rupture, Pneumothorax, MediastinitisRales Acute MI, Coronary Ischemia, Unstable Angina16Sorting It All OutHelpful Physical Exam findingsAbdominal ExamEpigastric TendernessLUQ TendernessRUQ TendernessNeurologic ExamFocal FindingsStroke

Epigastric Tenderness Esophageal Rupture, Esophageal Tear, Cholecystitis, PancreatitisLUQ Tenderness PancreatitisRUQ Tenderness Cholecystitis

Focal Findings Aortic DissectionStroke Acute MI, Coronary Ischemia, Aortic Dissection, Coronary Spasm

17Sorting It All OutField EvaluationEKGShould be performed within 10 minutes of patient contactAll male patients >33 years old and all female patients >39 years old with a pain complaint between the jaw and the belly buttonTime lost is muscle lost!New Injury PatternRight Heart StrainDiffuse ST segment elevation

New Injury Pattern suggestive of MI, should have therapy initiated immediately; notification of appropriate facility, activation of cath lab if availableRight Heart Strain consider PEDiffuse ST Elevation consider pericarditis18Sorting It All OutPrehospital Emergency CareMarch 19, 2013Field Activation of the Cath Lab Improves Door-to-Balloon TimeSmall, prospective observational studyParamedics trained to interpret 12-leads were permitted to bypass the ED and transport directly to the cath lab38 prehospital activations, 47 activations after arrival and 28 walk-ins90 minute door-to-balloon benchmark was met 100% of the time when activated ahead of time72% for activation after arrival68% for walk-ins

Sorting It All OutWhat are the cant miss causes of chest pain and SOB I need to worry about?Myocardial InfarctionUnstable AnginaAortic DissectionPulmonary EmbolismPneumothoraxEsophageal RupturePericarditis

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Sorting It All OutWhat are the cant miss causes of chest pain and SOB I need to worry about?Myocardial Infarction

Myocardial infarctionpain is moderately severe and rapid in onset. May be more pressure than pain. Usually retrosternal with radiation to neck, jaw, arms, epigastrium. Lasts more than 15-30 minutes and unrelieved by NTG.associated symptoms diaphoresis, nausea, vomiting, shortness of breathsupporting history may be brought on by emotional stress or exertion. Prodromal pain pattern usually elicited in history. Age >40, risk factors and male sex increase possibility.physical exam patients are anxious and uncomfortable. May be diaphoretic and show poor peripheral perfusion. No diagnostic physical exam findings for acute MI, but S3 and S4 heart sounds are supportive.EKG is the most useful test, changes seen in 80% of patients.

21Sorting It All OutWhat are the cant miss causes of chest pain and SOB I need to worry about?Unstable Angina

Unstable AnginaChanges in the pattern of angina with more severe, more prolonged or more frequent pain. Pain usually lasts >10 minutes. Unpredictable responses to NTG and rest.associated symptoms may be minimal; may have mild diaphoresis, nausea, SOB. May have increasing DOEsupporting history no clear relation to precipitating factors. Previous history of MI, age >40, risk factors, male sex all increase probability.physical exam nonspecific findings of transient nature, may be similar to MIEKG may be nonspecific or nondiagnostic

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Sorting It All OutWhat are the cant miss causes of chest pain and SOB I need to worry about?Aortic Dissection

Aortic Dissection90% of patients have rapid onset of severe pain that is maximal at the beginning. Pain may radiate to the back or abdomen. May be described as tearing and pain may migrateassociated symptoms neurologic complaints stroke, peripheral neuropathy, paresis or paraplegia related to dissection of vessels supplying the brain or spinal cord, poor peripheral pulses possiblesupporting history median age is 59, history of HTN in 70-90% of patients, 3:1 ratio male:female, Marfan syndrome and bicuspid aortic valve have increased incidencephysical exam elevated BP but poor peripheral perfusion. 50-60% of cases have asymmetrically decreased or absent peripheral pulses. 1-2% will also have coronary occlusion, renal, spinal cord insufficiencyEKG usually shows LVH, nonspecific.Ascending aortic aneurysms are usually managed surgically, descending aneurysms are usually managed medically

23Sorting It All OutWhat are the cant miss causes of chest pain and SOB I need to worry about?Pulmonary Embolism

Pulmonary EmbolismPain is often lateral and pleuritic in nature, central pain could be a massive clot. Pain usually abrupt in onset and maximal at the beginning.associated symptoms dyspnea and apprehension are most prominent. I feel like Im going to die. Cough is present in ~1/2 of cases. Hemoptysis occurs in