# ASA and Chest Palpitations



## broken stretcher (Mar 31, 2014)

21 yo F c/o 2/10 chest pain, palpitations, and dizziness sudden on set prior to calling 911.

Pt described the feeling as not so much pain as it was a feeling like her heart was going to skip out of her chest.     (Vitals HR:130  BP: 142/100  RR:18r)

I gave 4 aspirin as per c/p protocol. Another EMT stated that was the wrong thing to do because she was having "palpitations" not not "pain".

ASA...Right or wrong??


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## Medic Tim (Mar 31, 2014)

broken stretcher said:


> 21 yo F c/o 2/10 chest pain, palpitations, and dizziness sudden on set prior to calling 911.
> 
> Pt described the feeling as not so much pain as it was a feeling like her heart was going to skip out of her chest.     (Vitals HR:130  BP: 142/100  RR:18r)
> 
> ...



Past hx? What was your assessment,  12 lead, meds, etc.  
Was there any hx of anxiety or stress?

What you your assessment findings. Your not giving much info.


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## NomadicMedic (Mar 31, 2014)

Here's the thing, was she suffering from an ischemic event? Probably not. However, EMT protocols are usually designed to include everybody. The cast a very wide net. Is 325 of aspirin going to hurt her? Probably not.  

Did you do the right thing? Well, I wouldn't have treated her with aspirin or nitrates… But then again, I wasn't there.

Does she have a history of rapid heart rate? Has she consumed a bunch of energy drinks or coffee? Did she just get a speeding ticket? Did she break up with her boyfriend? Has she been eating and drinking normally? 


We don't (as a rule) treat simple sinus tach. A rate of 130 with no ectopy or ST changes gets the "okay, let's try and calm down a little…"


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## VFlutter (Mar 31, 2014)

I personally would not unless you are concerned about ACS for reasons other than "palpitations". Especially since her HR is 130. What rhythm was she in?


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## broken stretcher (Mar 31, 2014)

sorry a little more info... 

No hx of ANYTHING. (Cardiac, psych) 

Im also BLS first response (no 12 lead, no nitrates available to give unless assisting pt with her own which she does not have) and waiting on scene for 30+ due to being told by dispatch no ambulances available.

Pt appears to be resting comfortably, did not report any recent "anxiety inducing" events. 

No other abnormal findings.


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## teedubbyaw (Mar 31, 2014)

For an emt, it probably wasn't wrong. After all, nearly every hospital here has protocols to give ASA with any chest pain. 

As ALS, treatment would have most likely been different.


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## Underoath87 (Mar 31, 2014)

I'd strongly suspect drug use, particularly stimulants (even amphetamines prescribed for ADD).


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## Jmo371 (Mar 31, 2014)

for an basic that would be correct....


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## mycrofft (Mar 31, 2014)

As an atrial fib customer, I'd have taken some more aspirin myself if I suddenly went tachy despite my meds. Don't want to be juggling clots, you know. But as the owner-operator of my heart, I don't need a protocol and if it goes sideways somehow, I'm only risking myself.

With your level of training and the history, sit and wait would have been better-indicated. Maybe unlimber oxygen. Reassure and continue to monitor and record vs, etc.

Get hx, meds and medical allergies first thing as you are doing vitals. If the pt loses consciousness he or she can still be treated more safely than without those data.

EDIT: on second thought, what is her emergent complaint? If she is NAD, why did she call?


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## VFlutter (Mar 31, 2014)

Underoath87 said:


> I'd strongly suspect drug use, particularly stimulants (even amphetamines prescribed for ADD).



Why? Just because of the age? 

SVT, in patients without CVD, is most prevalent in young women. 

Hypothyroidism, stress, anxiety, infection, arrhythmia, etc is all on my Ddx along with drugs. With the information provided they all seem equally plausible. I am not going to automatically assume she pops pills just because she is 21.


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## mycrofft (Mar 31, 2014)

hyPERthyroid? 

I'd add caffeine intake also.


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## broken stretcher (Mar 31, 2014)

Pt denied any recreational drug use, reported she has been trying to CUT BACK on caffeine. I suspected some type of add med's too being that she was a 21yo college student in a dorm on the campus but she denied denied denied.


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## mycrofft (Mar 31, 2014)

Drug abuser's favorite river.
De Nile


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## EpiEMS (Mar 31, 2014)

DDX:

--Stimulant use (caffeine, most likely; Rx stimulants also possible)
--Anxiety, stress, other psychiatric condition
--SVT
--Hyperthyroid
--Infection
--Any others?

ASA wasn't "wrong" *by protocol*, I would imagine, but I would question whether it's necessary/beneficial.


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## Underoath87 (Mar 31, 2014)

Chase said:


> Why? Just because of the age?
> 
> *SVT, in patients without CVD, is most prevalent in young women.
> *
> Hypothyroidism, stress, anxiety, infection, arrhythmia, etc is all on my Ddx along with drugs. With the information provided they all seem equally plausible. I am not going to automatically assume she pops pills just because she is 21.



Sure, but does that mean that it is a more common cause of tachycardia and palpitations than stimulant use (and the associated acute malnutrition + dehydration) in college-aged women?


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## TheLocalMedic (Mar 31, 2014)

While the aspirin won't hurt her, it doesn't sound like the appropriate treatment for this patient.  Palpitations are not "chest pain", they are palpitations.  Calm and reassess, calm and reassess.  

Also, 30 minutes is quite a wait for an ambulance if you're in an urban environment, which I get the sense you were, OP.  You guys report that kind of stuff?


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## NPO (Apr 5, 2014)

My BLS protocol includes asprin for "suspected myocardial ischemia." Would I classify this as a suspected myocardial ischemia? Probably not, but as long as she doesn't have any known contraindications to it, it won't hurt. 

BLS protocols are generally designed to be CYA.


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## the_negro_puppy (Apr 5, 2014)

No. What anti-platelet benefit are you hoping to device from ASA administration?

This patient is not suffering ACS, no aspirin.


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## RebelAngel (May 3, 2014)

Had she eaten? Could it have been blood sugar issue? Did you check that?


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## JPINFV (May 3, 2014)

mycrofft said:


> Drug abuser's favorite river.
> De Nile



21 y/o female? I'd go with the Cri-Me-A River isn't just a waterway in Russia (and sometimes Ukraine).


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## JPINFV (May 3, 2014)

broken stretcher said:


> Pt denied any recreational drug use



In God I trust... everyone else gets a urine drug screen.


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## RebelAngel (May 3, 2014)

JPINFV said:


> 21 y/o female? I'd go with the Cri-Me-A River isn't just a waterway in Russia (and sometimes Ukraine).



At 21 years old I had never touched any sort of recreational drug (or herbal or mis-used prescriptions), and don't ever plan to at almost 32. I did however have issues with low blood sugar and anxiety that caused similar physical symptoms. Don't let potential hang up on probable drug use because "everyone" does it cloud judgment and cause you to overlook things.


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## NomadicMedic (May 3, 2014)

Vehement denial always raises my index of suspicion.


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## JPINFV (May 3, 2014)

RebelAngel said:


> At 21 years old I had never touched any sort of recreational drug (or herbal or mis-used prescriptions), and don't ever plan to at almost 32. I did however have issues with low blood sugar and anxiety that caused similar physical symptoms. Don't let potential hang up on probable drug use because "everyone" does it cloud judgment and cause you to overlook things.




Do you understand the concept of a differential diagnoses?

Do you understand that if you can't or actively don't consider a diagnosis you can't rule it out?

Do you not understand that people lie, especially young people when they think that they'll get into more trouble?

I'm not saying that it -is- drug use. I'm saying that drug use might be a cause, and as such when you have the ability to rule it out, you should do so. Perfect example. Middle age man with no psych history presents psychotic (seeing things, talking to himself, etc), fast heart rate, anxious. If you only did the drug screen, he tested meth positive. If you only checked the thyroid level, you would have found him to be hyperthyroid (thyrotoxicosis). If you considered BOTH as possible causes, you would have run both a thyroid panel and a drug screen and would have found both meth and thyrotoxicosis.


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## Medic Tim (May 3, 2014)

JPINFV said:


> Do you understand the concept of a differential diagnoses?
> 
> Do you understand that if you can't or actively don't consider a diagnosis you can't rule it out?
> 
> ...


you said the D word... no place for that in EMS

/sarcasm


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## Summit (May 3, 2014)

Simple answer: you followed the complaint based approach that defines EMT and you followed your protocol. 

The protocols are there because EMTs do not have sufficient education, training, and diagnostic tools to exercise thorough assessment and more flexible treatment. Consequently they all cover treatments have a massively low risk if unneeded vs a massively high potential reward if needed. THAT DOESN'T MEAN DISENGAGE YOUR BRAIN.

A thinking EMT might have utilized protocol flexibility to defer the ASA administration until completing more thorough assessment and possibly trying some other avenues. 

What can enable you when the protocol is not the best path? CALL MEDICAL CONTROL. The person on the other end of the biophone has the education and experience to confirm your concerns and illuminate you on thoughts you didn't have.


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## 18G (May 3, 2014)

I would not have given aspirin. A healthy 21 yo is highly unlikely to be having an ischemic cardiac event and the symptoms described don't lean towards such. 

Did it hurt? Of course not. People buy aspirin at walmart and take it everyday. But I'm not hearing any indication for aspirin.


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