chest pain and the bls provider by daniel b. green ii, nremt-p, ccp
TRANSCRIPT
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Chest Pain and the BLS ProviderBy
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
• Let’s 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