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Slide 2 Sorting It Out: Chest Pain, Cardiac Arrest and SOB Michael Lohmeier, MD June 24, 2014 Slide 3 Sorting It All Out Before I begin Thank You for this opportunity A Little About Me Michael Lohmeier Assistant Professor of Medicine, Emergency Med Medical Director; Madison Fire, FitchRona EMS, Middleton EMS, Dane County EMS, UW PD First Responders Medical Director, University of Wisconsin EEC Director, EMS Rotation for Residents Slide 4 Sorting It All Out PPer the Wisconsin EMS Association Website 5598,416 calls for EMS in 2011 115% increase from 2010 440% of calls are responded to by 10 services in the state IIn 1992, only 9% of Wisconsin ambulance services operated at the Paramedic level TToday, 32% of services are licensed at this level 668% 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 situations TThats 59,000 patients per year! https://www.wisconsinems.com/ems-for-the-general-public/wisconsin-ems-statistics/ Slide 5 Sorting It All Out Quotable The only man who never makes a mistake is the man who never does anything. -Theodore Roosevelt Slide 6 Sorting It All Out Why should you care? Chest Pain is one of the most common reasons for activating 9- 1-1 Unofficial Dane County Data Emergency Department data Not everything that presents with chest pain is cardiac Time lost is muscle lost EMS is triaged to cardiac cath labs in many parts of the state The public expects you to get it right Misdiagnosing an MI can be deadly! Aortic dissection Pericarditis http://www.cdc.gov/nchs/fastats/emergency-department.htm http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2010_ed_web_tables.pdf Slide 7 Sorting It All Out Chest 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 2010 5.4% of visits for chest pain 2.7% of visits for shortness of breath 2.7% of visits for cough Critical diagnoses causing either varies widely ACS, aortic dissection, pulmonary embolism, tension pneumothorax, pericardial tamponade, esophageal rupture http://www.cdc.gov/nchs/fastats/emergency-department.htm Slide 8 Sorting It All Out Differentials Chest Pain Acute MI Unstable Angina PE Aortic Dissection Pneumothorax Cardiac Tamponade Esophageal Rupture Pericarditis Shortness of Breath Asthma and COPD Pneumonia Pneumothorax Pulmonary Embolism Trauma Acute Coronary Syndrome Endocrine (DKA, metabolic acidosis) Hematologic (anemia) Toxins (Salicylate overdose) Ascites Slide 9 Sorting It All Out Differentials Chest Pain Acute MI Unstable Angina PE Aortic Dissection Pneumothorax Cardiac Tamponade Esophageal Rupture Pericarditis Shortness of Breath Asthma and COPD Pneumonia Pneumothorax Pulmonary Embolism Trauma Acute Coronary Syndrome Endocrine (DKA, metabolic acidosis) Hematologic (anemia) Toxins (Salicylate overdose) Ascites Slide 10 Sorting It All Out What 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 ganglia These ganglia overlap the 3 segments above and below Location and quality of the pain are indistinct to the patient Can be from the jaw to the epigastrium Some somatic afferent fibers synapse in the same dorsal root ganglia and can confuse the CNS Gives referred pain Slide 11 Sorting It All Out What causes shortness of breath? dyspnea is the term used for the sensation of breathlessness and the patients reaction Neither the clinical severity nor the patients perception correlates well with the seriousness of underlying pathology The actual mechanisms for dyspnea are unknown Imbalance between the respiratory center in the medulla oblongata and the chemoreceptors near the carotid bodies Increased work of breathing Increased respiratory drive Slide 12 Sorting It All Out Just to recap Chest Pain is indistinct to the patient, source may be unclear on exam Dyspnea is subjective, may be related to a physical, metabolic or psychiatric condition Differential is enormous, from non-emergent to the most critical diagnoses in medicine Awesome. http://healthinessbox.files.wordpress.com/2012/09/chest_pain.jpg Slide 13 Sorting It All Out What are the life threats, and does this patient need an intervention immediately? There is no simple algorithm Keep your approach organized and systematic Keys to narrow down your differential will be in the history, physical exam and EKG in ~90% of patients Majority of diagnosis is going to come from the history If theyre already in cardiac arrest, run the ACLS algorithms Designed to treat the underlying etiologiy of arrest We want to prevent that from happening! Slide 14 Sorting It All Out History Dont forget your O-P-Q-R-S-T! Onset What were you doing when you started having pain? Provocation or palliation What makes the pain better or worse? Quality Can you describe the pain? Sharp, dull, achy, stabbing, burning? Region and Radiation Where is the pain, and does it go anywhere? Severity On a scale of 0-10 with zero being no pain, how bad does this hurt? Timing How long has this been going on and how has it changed since the beginning? http://www.emtresource.com/resources/acronyms/opqrst/ Slide 15 Sorting It All Out HHistory AA history of prior pain and the diagnosis can be quite helpful in narrowing down your differential BBut beware the biggest barrier to making the correct diagnosis is TThe previous diagnosis!! AAssociated symptoms may be helpful as well DDiaphoresis should suggest a serious or visceral cause HHemoptysis is a classic PE sign that is seen in about 1/5 the time NNausea and Vomiting can be GI or cardiac in nature RRisk factors are important to consider when evaluating a patient GGood to know from a population basis, not as helpful with the individual Slide 16 Helpful Physical Exam findings Appearance Acute Respiratory Distress Diaphoresis Vital Signs Hypotension Tachycardia Bradycardia Hypertension Fever Hypoxemia Slide 17 Sorting It All Out Helpful Physical Exam findings Cardiovascular Exam Asymmetric Upper Extremity Blood Pressures Narrow Pulse Pressure New Murmur S3/S4 Gallop Pericardial Rub Audible Systolic Crunch (Hammans Sign) JVD Pulmonary Exam Unilateral Diminished Breath Sounds Pleural Rub Subcutaneous Emphysema Rales Slide 18 Sorting It All Out Helpful Physical Exam findings Abdominal Exam Epigastric Tenderness LUQ Tenderness RUQ Tenderness Neurologic Exam Focal Findings Stroke Slide 19 Sorting It All Out Field Evaluation EKG Should be performed within 10 minutes of patient contact All male patients >33 years old and all female patients >39 years old with a pain complaint between the jaw and the belly button Time lost is muscle lost! New Injury Pattern Right Heart Strain Diffuse ST segment elevation Slide 20 Sorting It All Out Prehospital Emergency Care March 19, 2013 Field Activation of the Cath Lab Improves Door-to-Balloon Time Small, prospective observational study Paramedics trained to interpret 12-leads were permitted to bypass the ED and transport directly to the cath lab 38 prehospital activations, 47 activations after arrival and 28 walk- ins 90 minute door-to-balloon benchmark was met 100% of the time when activated ahead of time 72% for activation after arrival 68% for walk-ins Slide 21 Sorting It All Out What are the cant miss causes of chest pain and SOB I need to worry about? Myocardial Infarction Unstable Angina Aortic Dissection Pulmonary Embolism Pneumothorax Esophageal Rupture Pericarditis Slide 22 Sorting It All Out What are the cant miss causes of chest pain and SOB I need to worry about? Myocardial Infarction Slide 23 Sorting It All Out What are the cant miss causes of chest pain and SOB I need to worry about? Unstable Angina Slide 24 Sorting It All Out What are the cant miss causes of chest pain and SOB I need to worry about? Aortic Dissection Slide 25 Sorting It All Out What are the cant miss causes of chest pain and SOB I need to worry about? Pulmonary Embolism Slide 26 Sorting It All Out What are the cant miss causes of chest pain and SOB I need to worry about? Pneumothorax Slide 27 Sorting It All Out What are the cant miss causes of chest pain and SOB I need to worry about? Esophageal Rupture Slide 28 Sorting It All Out What are the cant miss causes of chest pain and SOB I need to worry about? Pericarditis Slide 29 Sorting It All Out Summary Chest Pain and Shortness of Breath Very common reasons to seek medical treatment NOT very easy to sort out Etiology from the benign to the immediately life threatening The burden is on us the medical providers to figure out whats happening with the patients Most of the answer comes through the history and 12-lead If you dont act on the information you get, the patient can arrest! Slide 30 Sorting It All Out Slide 31 Quotable I never did a days work in my life. It was all fun. -Thomas Edison Slide 32 Sorting It All Out TThank You! Slide 33 Slide 34 Slide 35 References CONE DC, Lee CH, Van Gelder C EMS activation of the cardiac catheterization laboratory is associated with process improvements in the care of myocardial infarction patients. Prehosp Emerg Care. 2013;17:293-8. http://jama.jamanetwork.com/article.aspx?articleid=1568253 http://jama.jamanetwork.com/article.aspx?articleid=1568253 http://ecg.utah.edu/lesson/9 http://ecg.utah.edu/lesson/9 http://www.nursingconsult.com/nursing/patient- education/image?DOCID=10087&PAGE=en_%7B5184704e-d597-4edd-b169- dd09df788588%7D.jpg&module=patEdu http://www.nursingconsult.com/nursing/patient- education/image?DOCID=10087&PAGE=en_%7B5184704e-d597-4edd-b169- dd09df788588%7D.jpg&module=patEdu http://en.wikipedia.org/wiki/Aortic_dissection http://en.wikipedia.org/wiki/Aortic_dissection http://www.nhlbi.nih.gov/health/health-topics/images/pericarditis.jpg http://www.nhlbi.nih.gov/health/health-topics/images/pericarditis.jpg http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2010_ed_web_tables.pdf http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2010_ed_web_tables.pdf http://afghanheart.files.wordpress.com/2013/02/my-cards-pneumothorax.jpg http://afghanheart.files.wordpress.com/2013/02/my-cards-pneumothorax.jpg http://emstopics.com/ChestPainReadingMain.htm http://emstopics.com/ChestPainReadingMain.htm http://www.cdemcurriculum.org/ssm/cardiovascular/cv_acs.php http://www.cdemcurriculum.org/ssm/cardiovascular/cv_acs.php