Chest Pain and the BLS ProviderBy

Daniel B. Green II, NREMT-P, CCP

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

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

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

Prevention Strategies• Educational Programs

– Nutrition– Smoking Cessation

• Recognition of Symptoms and Prompt Intervention

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

Cardiac Anatomy and Physiology• Epicardium

– Outermost layer (Visceral Pericardium)

• Myocardium– Thick middle layer

• Endocardium– Smooth, inner layer of

connective tissue

Chambers of the Heart• Atria

– Superior chambers– Less muscular

• Ventricles– Inferior chambers– More muscular

• Left is 3 times thicker than right

Heart Valves• Primary Function

– Prevent blood from flowing backward

• AV valves– Between atria and ventricles– Tricuspid (Right)– Mitral (Left)

• Semiluner Valves– Pulmonic– Aortic

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

Coronary Arteries• Carry 200-250 ml each

minute• Left coronary artery

carries 85%– LAD– Circumflex

• Right coronary carries remaining volume

Conduction System• Cardiac muscle is unique

– Automaticity– Excitability– Conductivity– Contractility

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

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)

Focused Cardiac Exam• Should include 3 components

– Identify a chief complaint– History of the event and significant medical

history– A physical examination

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

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

History of Present Illness• Chest Pain

– Most common chief complaint

– Use OPQRST• Use clear questions• Keep it simple

History of Present Illness• Dyspnea

– Main symptom of heart failure– Can be caused by other medical problems

• COPD• Respiratory Infection• Pulmonary Embolus• Asthma

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

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?

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

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

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

Angina Pectoris Management• Request ALS Intercept if not on scene• Position of comfort• Oxygen• Medications

– Aspirin– Nitroglycerin

• Prompt transport• Prompt notification of receiving facility

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

MI Management• Request ALS intercept if not on scene• Position of Comfort• Oxygen• Medications

– Aspirin– Nitroglycerin

• Prompt transport• Prompt notification of receiving facility

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

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

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

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

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

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

Non-Cardiac Causes of Chest Pain• Cholecystitis• Hiatal Hernia• Pancreatitis• Pleural Irritation• Pneumothorax• Tumors

Differential Diagnosis• Provocation• Quality• Radiation

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

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

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

CHF Management• Request ALS Intercept if not on scene• Patient positioning• High-flow oxygen

– NRB

• Pulse oximetry• Prompt transport

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