Ruling out MI - Pressing on Patient's Chest

[sdafbkfsdbkjdsf]

Hello all,
I've been hearing from a couple of medics that if you have a pt who has a chief complaint of chest pain. And if they were to complain of pain when you press on their chest where the heart lays you can "rule out" an MI. I'm just interested if you guys ever heard of this before.

 

[NomadicMedic]

Reproducible chest pain is most often musculoskeletal rather than ischemic, but I certainly wouldn't "rule out" an MI by just pushing on someone's chest.

 

[EMSrush]

For what it's worth, none of our equipment can "rule out" an MI.

 

[NomadicMedic]

For what it's worth, none of our equipment can "rule out" an MI.

Very true. A12 lead, a troponin and a trip to the cath lab are the steps in ruling out an MI.

As for a BLS assessment, if you have a patient that's been lifting boulders in his backyard for a landscape project and now he has chest pain made worse on palpation, I'd lean toward musculoskeletal pain. The same way I'd consider point specific, sharp pleuritic pain in a patient who has been coughing up green gunk as a non cardiac problem.

However, a patient with a cardiac history or a patient that presents with any of the other typical "MI signs" should get an ALS evaluation.

 

[RocketMedic]

The "pain on palp" is a highly leading and subjective question. Presentation and history will be far better guides.

Pain that changes on respiration, palpation or motion is probably not cardiac, but it's a lot to rule out.

 

[Achilles]

Isn't there a test that can be done with the phosphocreatine levels to detect if a PT has had an MI?

 

[Sublime]

Isn't there a test that can be done with the phosphocreatine levels to detect if a PT has had an MI?

As far as I know Troponin and CKMB are the only diagnostic tests used in diagnosing MI. Never seen a doc order phosphocreatine levels in a chest pain patient.

To the OP. Like others have said reproducible chest pain on palpitation is highly suggestive of non-cardiac related pain. But you certainly can't rule it out without labs.

 

[triemal04]

Don't fall into that trap, and if your partner does quietly smack them upside the head.

Multiple studies have shown that people with diagnosed AMI's can have reproducable pain and/or chest wall tenderness and/or point tenderness. Think it's been as high as 15% or more in a couple.

This isn't to say that you shouldn't check for that, just that you need to apply the results to your overall opinion of what is going on and not use it as your sole criteria for ruling a MI in or out.

 

[Smash]

As Triemal says, around 15% of true MI has pain that is reproducible. Not a good number to take a punt on I reckon.

 

[the_negro_puppy]

Don't fall into that trap, and if your partner does quietly smack them upside the head.

Multiple studies have shown that people with diagnosed AMI's can have reproducable pain and/or chest wall tenderness and/or point tenderness. Think it's been as high as 15% or more in a couple.

This isn't to say that you shouldn't check for that, just that you need to apply the results to your overall opinion of what is going on and not use it as your sole criteria for ruling a MI in or out.

This. While there are certain characteristics that make A.M.I / ACS more likely, nothing is certain or set in stone. Age, co-morbidities and other factors can all influence presentation, with there not really being a 'typical' presentation these days. If you think of the organs/pathophysiology of different causes of chest pain, it really needs to be taken seriously to exclude the more serious causes that can cause big trouble if missed.

I don't think I have ever not transported a chest pain patient. When you think about it, the pt is so worried that they have called 911/000 it PROBABLY deserves further evaluation. Even the 20 y.o F pt who has just broken up with her boyfriend, hyperventilating and crying c/o chest pain probably needs to be transported. You might be able to calm them down, but they will probably ring back in 30 minutes. People will probably disagree.

 

[Medic Tim]

As Triemal says, around 15% of true MI has pain that is reproducible. Not a good number to take a punt on I reckon.

I have also read it is in the 15%-20% range

 

[Clare]

There is no one test that can be done in the pre-hospital environment to rule in or rule out MI. Chest pain that is only present upon palpation or movement is in theory more likely to be MSK pain but chest pain severe or worrying enough for somebdy to call an ambulance is myocardial ischaemia until a very clear and very obvious alternate cause is identified.

 

[Aidey]

... chest pain severe or worrying enough for somebdy to call an ambulance is myocardial ischaemia until a very clear and very obvious alternate cause is identified.

:rofl: :rofl: :rofl:

I think that might be just a tad of an overstatement.

 

[Christopher]

Hello all,
I've been hearing from a couple of medics that if you have a pt who has a chief complaint of chest pain. And if they were to complain of pain when you press on their chest where the heart lays you can "rule out" an MI. I'm just interested if you guys ever heard of this before.

You push on a STEMI patient's chest hard enough...it'll hurt. The test is suspect

 

[Christopher]

There is no one test that can be done in the pre-hospital environment to rule in or rule out MI.

We certainly can rule in an MI in the field, we can even rule in which artery is closed...

 

[NomadicMedic]

True aidey. It seems like many of my chest pain calls are the result of an over active imagination fueled by the "I'm having a heart attack" bayer aspirin commercials.

But, I always err on the side of caution.

 

[Clare]

We certainly can rule in an MI in the field, we can even rule in which artery is closed...

You can make a provisional diagnosis of MI yes but such a diagnosis is subject to confirmation.

It's not hard to go "I think you are having an MI" if you're doubled over with chest pain, grey as a winter cloud and having crazy ST changes but something like half of all patients who have an AMI present with normal physical examination and/or normal ECG.

There is no one test that is specific and sensitive enough to rule in or out an MI especially in pre-hospital without blood tests and angiography.

A provisional diagnosis must take into account all the findings from history, assessment and a good quality 12 lead ECG.

If there is not a very clear and very obvious non-cardiac cause for somebody who has chest pain and they have cardiovascular risk factors (e.g. age, hypertension, hypercholesterolaemia, previous MI/IHD, diabetic, smoker, obese etc) then they are getting transported.

 

[Christopher]

You can make a provisional diagnosis of MI yes but such a diagnosis is subject to confirmation.

It's not hard to go "I think you are having an MI" if you're doubled over with chest pain, grey as a winter cloud and having crazy ST changes but something like half of all patients who have an AMI present with normal physical examination and/or normal ECG.

There is no one test that is specific and sensitive enough to rule in or out an MI especially in pre-hospital without blood tests and angiography.

A provisional diagnosis must take into account all the findings from history, assessment and a good quality 12 lead ECG.

If there is not a very clear and very obvious non-cardiac cause for somebody who has chest pain and they have cardiovascular risk factors (e.g. age, hypertension, hypercholesterolaemia, previous MI/IHD, diabetic, smoker, obese etc) then they are getting transported.

Is "provisional diagnosis" somehow not "rule in"? I wouldn't give ASA or NTG if I didn't "rule in" ACS. I'm not quite sure what you're trying to say here.

(And I wasn't talking about frank ST/T-wave changes, 1mm+ in 2+ leads isn't a tough call and is a poor definition for "ruling in" or "ruling out" an MI.)

 

[Aidey]

True aidey. It seems like many of my chest pain calls are the result of an over active imagination fueled by the "I'm having a heart attack" bayer aspirin commercials.

But, I always err on the side of caution.

Or they are people who have figured out that "chest pain" is one of the magic phrases that gets people there faster. Or the people who were led there by the non EMD dispatch center during their triage of the 911 call. Sorry dispatch, but "My upper chest hurts from throwing up" is not a delta chest pain call.

 

[Christopher]

Or they are people who have figured out that "chest pain" is one of the magic phrases that gets people there faster. Or the people who were led there by the non EMD dispatch center during their triage of the 911 call. Sorry dispatch, but "My upper chest hurts from throwing up" is not a delta chest pain call.

And if it isn't Delta traffic chest pain it is 6-D-1 because they're having trouble breathing...because they're puking...