Sorting It Out: Chest Pain, Cardiac Arrest and SOB

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Sorting It Out: Chest Pain,
Cardiac Arrest and SOB
Michael Lohmeier, MD
June 24, 2014
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
Sorting It All Out…
 Per the Wisconsin EMS Association Website
 598,416 calls for EMS in 2011
 15% increase from 2010
 40% of calls are responded to by 10 services in the state
 In 1992, only 9% of Wisconsin ambulance services operated at
the Paramedic level
 Today, 32% of services are licensed at this level
 68% 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
 That’s 59,000 patients per year!
https://www.wisconsinems.com/ems-for-the-general-public/wisconsin-ems-statistics/
Sorting It All Out…
 Quotable
 “The only man who never
makes a mistake is the
man who never does
anything.”
-Theodore Roosevelt
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
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
Sorting It All Out…
 Differentials
 Chest Pain
 Acute MI

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
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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
Sorting It All Out…
 Differentials
 Chest Pain
 Acute MI

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
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
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
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
Sorting It All Out…
 What causes shortness of
breath?
 “dyspnea” is the term used for
the sensation of
breathlessness and the
patient’s reaction

Neither the clinical severity
nor the patient’s 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
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
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 they’re already in cardiac arrest, run the ACLS algorithms
 Designed to treat the underlying etiologiy of arrest
 We want to prevent that from happening!
Sorting It All Out…

History

Don’t forget your O-P-Q-R-S-T!
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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/
Sorting It All Out…
 History
 A history of prior pain and the diagnosis can be quite helpful in
narrowing down your differential
 But beware – the biggest barrier to making the correct diagnosis
is…
 The previous diagnosis!!
 Associated symptoms may be helpful as well
 Diaphoresis should suggest a serious or visceral cause
 Hemoptysis is a classic PE sign – that is seen in about 1/5 the time
 Nausea and Vomiting can be GI or cardiac in nature
 Risk factors are important to consider when evaluating a patient
 Good to know from a population basis, not as helpful with the
individual
Sorting It All Out…
 Helpful Physical Exam findings
 Appearance
 Acute Respiratory Distress
 Diaphoresis
 Vital Signs
 Hypotension
 Tachycardia
 Bradycardia
 Hypertension
 Fever
 Hypoxemia
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” (Hamman’s Sign)
 JVD
 Pulmonary Exam
 Unilateral Diminished Breath Sounds
 Pleural Rub
 Subcutaneous Emphysema
 Rales
Sorting It All Out…
 Helpful Physical Exam findings
 Abdominal Exam
 Epigastric Tenderness
 LUQ Tenderness
 RUQ Tenderness
 Neurologic Exam
 Focal Findings
 Stroke
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
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
Sorting It All Out…
 What are the “can’t miss” causes of chest pain and SOB I
need to worry about?
 Myocardial Infarction
 Unstable Angina
 Aortic Dissection
 Pulmonary Embolism
 Pneumothorax
 Esophageal Rupture
 Pericarditis
Sorting It All Out…
 What are the “can’t miss” causes of chest pain and SOB I
need to worry about?
 Myocardial Infarction
Sorting It All Out…
 What are the “can’t miss” causes of chest pain and SOB I
need to worry about?
 Unstable Angina
Sorting It All Out…
 What are the “can’t miss” causes of chest pain and SOB I
need to worry about?
 Aortic Dissection
Sorting It All Out…
 What are the “can’t miss” causes of chest pain and SOB I
need to worry about?
 Pulmonary Embolism
Sorting It All Out…
 What are the “can’t miss” causes of chest pain and SOB I
need to worry about?
 Pneumothorax
Sorting It All Out…
 What are the “can’t miss” causes of chest pain and SOB I
need to worry about?
 Esophageal Rupture
Sorting It All Out…
 What are the “can’t miss” causes of chest pain and SOB I
need to worry about?
 Pericarditis
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 what’s
happening with the patients
 Most of the answer comes through the history and 12-lead
 If you don’t act on the information you get, the patient can
arrest!
Sorting It All Out…
Sorting It All Out…
 Quotable
 “I never did a day’s work in
my life. It was all fun.”
-Thomas Edison
Sorting It All Out…
Thank You!
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References
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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://ecg.utah.edu/lesson/9
http://www.nursingconsult.com/nursing/patienteducation/image?DOCID=10087&PAGE=en_%7B5184704e-d597-4edd-b169dd09df788588%7D.jpg&module=patEdu
http://en.wikipedia.org/wiki/Aortic_dissection
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://afghanheart.files.wordpress.com/2013/02/my-cards-pneumothorax.jpg
http://emstopics.com/ChestPainReadingMain.htm
http://www.cdemcurriculum.org/ssm/cardiovascular/cv_acs.php

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