# Chest Pain Patient



## Rialaigh (Nov 12, 2014)

Called out for chest pain around 10pm, 50 year old female complaining of chest pain and also fell down.

Upon arrival find 50 year old female lying in floor in living room complaining of chest pain and headache and she "hit her head". Patient states she fell down and she doesn't know why, hit her head on the carpet. Patient has also been having intermittent chest pain for 3 days, a couple times a day. But about 2.5 hours ago it has become constant sharp pain 8/10, substernal on the left side extending around the ribs to her back. Patient denies neck or back pain or additional trauma. 

Patient has a medical history of migraine headaches with accompanied seizures a few times a month, however states that only happens if she messes up her medications. Patient takes Tramadol, gabapentin, and amitriptyline. Patient is compliant with her meds. Patient has no other medical history at all. Patient sees primary care on a regular basis and states she has not been to a hospital at all in over 15 years. Only surgical history was a knee replacement when she was in her early 30's. 

Onset of chest pain 2.5 hours ago accompanied by shortness of breath with chest pain worse upon inspiration but not palpation. Patient states no nausea. Patient is midly diaphoretic and appears not well. Patients family has history of heart problems, father, two brothers, and two uncles have all died from cardiac related problems and another uncle has had a heart transplant. Patient is in good shape, relatively athletic, smokes a few ciggarettes a day and consumes no alcohol and does no drugs. Patient is 5'9 and ways 145. 

Initial vitals are 
BP - 160/100
HR - 84 
O2 % - 98 on room air
RR - 20 and shallow (All lung fields clear)
BgL - 98 


 this is the third 12 lead obtained a couple minutes after getting her in ambulance, patient appears anxious, short of breath, and in substantial pain. 


Any concern from the 12 lead? Community band aid station is 5 minutes priority2.... PCI center is 30 minutes priority1.... Trauma Center/PCI center is 1 hour priority1 or a hop skip and a jump by helicopter. 



Course of action?  Decision making process? is this a "standard" chest pain call for you? 


If you have any additional questions I can likely provide answers about patient presentation.


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## teedubbyaw (Nov 12, 2014)

Did you evaluate for a PE?

Her inferior leads and high lateral reciprocal changes are of slight concern, but there's something else going on.


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## Gurby (Nov 12, 2014)

Seems like an easy nitro+aspirin + trip to the bandaid station to me, but I'm only a medic student.  Community hospital can draw labs and do tests, and start her on fibrinolytics if need be.

If you're really concerned about how she looks, you could get on the phone with med control / telemetry to hospital: "Hey doc, the EKG looks fine but I have a bad feeling and she has a lot of family deaths due to cardiac issues - what do you think?"  That also takes the liability off of you.


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## blachatch (Nov 15, 2014)

Inferior leads look suspect to me.


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## Clare (Nov 15, 2014)

She needs to be referred to ED based on

1) New presentation
2) Her blood pressure is very high for somebody with no PMHx of HTN
3) The 1 mm elevation of her S in leads II, III and aVF.  
4) She needs at least basic bloods and cardiac markers e.g. CKmb and troponin, possibly a CXR too. 

I cannot confidently rule out that her pain is not cardiac in nature and that she doesn't have some significant illness underlying such as a somewhat atypical MI or pulmonary embolism.  Her FMHx is also quite concerning. 

Now, as far as treatment, I'd give her aspirin and a test dose of 0.8 mg of GTN to see how therapeutic it was.  

If she would like some analgesia then entonox is good to start with.  

Take her to the PCI capable hospital directly, do not stop at the non PCI hospital.


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## ERDoc (Nov 16, 2014)

I agree with what others have said.  You have a woman with a syncopal episode and chest pain.  Cardiac should be high on the list, and even higher given the horrible family history.  This pt doesn't need a cath lab right now (though that may change).  Right now, I think we are looking at a straightforward rule out.


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## Gurby (Nov 16, 2014)

ERDoc said:


> I agree with what others have said.  You have a woman with a syncopal episode and chest pain.  Cardiac should be high on the list, and even higher given the horrible family history.  This pt doesn't need a cath lab right now (though that may change).  Right now, I think we are looking at a straightforward rule out.



What are your thoughts on the transport decision?  If you're the doc at the small local hospital, are you pissed off if I bring you this patient?


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## ERDoc (Nov 16, 2014)

Nope, I'd be fine with it.  I will move them along if they need anything more than a rule out and stress test.  Of course, it depends on what your hospital can do.  If they can't stress a pt, then better to take them to the next hospital.


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## Clare (Nov 16, 2014)

I think all hospitals stress patients, treadmill or not! 

I was once told it's not a matter of thinking whether or not the hospital you are thinking might be better wants to accept the patient (they generally always will). it's a matter of whether or not they tell you not to take the patient to the other hospital.  

Example - In New Zealand we have a poor network for major trauma, it's very much in it's infancy and probably a decade behind the rest of the world, particularly London and most of the United States.  There are a number of places that insist patients are taken to the local hospital rather than choppering them out direct to a major trauma hospital (due to the distances involved it's generally always going to be by air).  It's not a case of thinking "gee, will this hospital accept such a sick patient?" but rather one of "does the major hospital think it's appropriate for the patient to go to the non-major hospital" because it's a bit like asking Mr Fox if he wants to investigate the chicken coup, he always will but, if you ask the farmer, he will tell you it's a bad idea and that he should do it instead.  The fox being analogous to the small hospital and the farmer being the major hospital.


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## ERDoc (Nov 16, 2014)

I think the correct question is, "Does whatever hospital you are taking your pt to have the appropriate facilities for the pt?"  One of the hospitals I work at does not have dialysis capabilities so I pull my hair out every time EMS bring a dialysis pt in.  There was a time when sometimes we would have ortho coverage, sometimes we wouldn't.  EMS knew to call and ask.

In the US, any hospital you show up at has to take your pt whether they like it or not.


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## Jim37F (Nov 16, 2014)

This is why I'm glad out of the 4 hospitals we routinely go to, 3 are STEMI Receiving Centers (the 3 closest to me) and 3 are Approved Stroke Centers (only the one closest to me isn't an ASC though supposedly they're working on becoming one). Plus I have 2 Trauma Centers less than 30 min from me (one a Level 1 the other a Level 2, which as I understand it has all the capabilities just doesn't do the teaching but I could be wrong) Plus a dedicated Children's Hospital about 30 min out as well.....yes I do realize just how spoiled I am here lol


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## Jim37F (Nov 17, 2014)

But that being said, as an EMT, I can't rule in or out a STEMI....with the signs and symptoms presented here, and especially with the significant and repeated family history, I would feel more comfortable taking the patient directly to the PCI capable hospital, if the patient ends up needing it, why have them sit and wait potentially hours before the local "band aid station" to arrange an IFT when you can just get them to where they need now? I would talk to the patient, ask them which hospital they normally go to, and which one they actually want to go to, who knows, maybe they're already requesting to go see their normal cardiologist at the PCI hospital 30min out? If they wanted the local one, I would explain that their condition may require the services at the further hospital and I'd like to take them straight there...in any case I'll be calling up OLMC for further guidance


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## Clare (Nov 17, 2014)

There is an argument that could be made for being guided by automatic interpretation at EMT level however it's not overly strong given the limitations and differences between monitor software.  

Locally there is the option to transmit the ECG to the ICP in Control for their evaluation and guidance.  If I wasn't able to confidently interpret the ECG myself then I would do that.


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## Rialaigh (Nov 17, 2014)

Is anyone calling this a Stemi in your system or pre alerting the hospital for possible stemi


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## Tigger (Nov 17, 2014)

Clare said:


> I think all hospitals stress patients, treadmill or not!
> 
> I was once told it's not a matter of thinking whether or not the hospital you are thinking might be better wants to accept the patient (they generally always will). it's a matter of whether or not they tell you not to take the patient to the other hospital.
> 
> Example - In New Zealand we have a poor network for major trauma, it's very much in it's infancy and probably a decade behind the rest of the world, particularly London and most of the United States.  There are a number of places that insist patients are taken to the local hospital rather than choppering them out direct to a major trauma hospital (due to the distances involved it's generally always going to be by air).  It's not a case of thinking "gee, will this hospital accept such a sick patient?" but rather one of "does the major hospital think it's appropriate for the patient to go to the non-major hospital" because it's a bit like asking Mr Fox if he wants to investigate the chicken coup, he always will but, if you ask the farmer, he will tell you it's a bad idea and that he should do it instead.  The fox being analogous to the small hospital and the farmer being the major hospital.



We still have a similar issue in much rural America. Small hospitals need patient volume to keep their doors open and are not apt to decline patients, even though both sides are well aware that they are ill-equipped for many patients. If I was the patient I would not want two ED and two ambulance bills.


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## ERDoc (Nov 17, 2014)

That depends on the hospital.  There are quite a few rural hospitals that are Critical Access Hospitals and must not be above a certain size.  If they get too big, they lose the CAH designation and the money that comes with it.  We had a hospital around this area recently that shut down one of its speciality services (GI or ortho, I think) because they had too many inpatients and were at risk of losing their designation.

As for the OP, keep in mind that a small percentage of pts actually need a cath lab.  Most can be ruled out at any semi-decent hospital or end up having other diagnoses (PE, pneumonia, CHF, pneumothorax, etc) which can be handled at most hospitals.


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## EMT11KDL (Nov 29, 2014)

Was right sided leads obtained? with inferior leads having some elevation about 1mm, i would do right side leads, and see if you have more ST Elevation on the Right side of the heart,


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## doc610 (Nov 30, 2014)

ERDoc said:


> I think the correct question is, "Does whatever hospital you are taking your pt to have the appropriate facilities for the pt?"  One of the hospitals I work at does not have dialysis capabilities so I pull my hair out every time EMS bring a dialysis pt in.  There was a time when sometimes we would have ortho coverage, sometimes we wouldn't.  EMS knew to call and ask.
> 
> In the US, any hospital you show up at has to take your pt whether they like it or not.


 Nice to see a fellow physician on this forum!


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## ERDoc (Dec 1, 2014)

doc610 said:


> Nice to see a fellow physician on this forum!


Hey 610.  I've lurked for a while but finally decided to register.  Seems like a good bunch of people here.


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## Christopher (Dec 3, 2014)

Syncope is an odd presentation during STEMI outside of cardiogenic shock or an arrhythmia. The ECG itself does not really provide us anything to hang our hat on, even though perhaps we could argue for ST/T-wave changes in aVL.

Serial ECG's and a trip to the closest appropriate facility. No STEMI activation from me on that ECG alone.


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## Brandon O (Dec 6, 2014)

Maybe pass on the aspirin. Kinda worrisome for dissection.


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## Gurby (Dec 6, 2014)

Brandon O said:


> Maybe pass on the aspirin. Kinda worrisome for dissection.



Dissection is more common in males, and she's a bit on the young side to have one.  Apparently no Hx of connective tissue problems, no trauma, no Hx of HTN.
On the other hand, her whole family has died of cardiac issues, and she's in the danger zone for that age-wise.

Obviously I could be wrong, but I strongly disagree?  It just seems SO much more likely to be something cardiac or a PE, IMO.  Not giving aspirin seems really bad to me here.


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## Brandon O (Dec 7, 2014)

Gurby said:


> Dissection is more common in males, and she's a bit on the young side to have one.  Apparently no Hx of connective tissue problems, no trauma, no Hx of HTN.
> On the other hand, her whole family has died of cardiac issues, and she's in the danger zone for that age-wise.
> 
> Obviously I could be wrong, but I strongly disagree?  It just seems SO much more likely to be something cardiac or a PE, IMO.  Not giving aspirin seems really bad to me here.



None of that is really dispositive, but I agree that by odds I'd probably lean toward PE. I think the only real error would be not considering it. 

I'd go to nearest facility as long as they have full imaging capabilities and don't suck. Serial ECGs will help too. We can spitball on the risk/benefit of the aspirin thing... wonder if anyone has any data on risk ratio in TAD.


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## Gurby (Dec 7, 2014)

Brandon O said:


> None of that is really dispositive, but I agree that by odds I'd probably lean toward PE. I think the only real error would be not considering it.
> 
> I'd go to nearest facility as long as they have full imaging capabilities and don't suck. Serial ECGs will help too. We can spitball on the risk/benefit of the aspirin thing... wonder if anyone has any data on risk ratio in TAD.



Heart disease killed 600,000 people in 2010.  I couldn't find any data on aortic dissection, but wikipedia says they occur at a rate of ~3/100,000 people per year.  It doesn't say how many of those people die, but let's just assume they all die for simplicity's sake... Given US population of 3 million we can estimate that 90 people died of dissections in 2010 (though this is probably an overestimate)...

You had better have a damn good history if you're going to withhold aspirin from this patient because you suspect dissection.  I don't think there's anywhere close to enough evidence here.  If she had a connective tissue disorder or one ran in the family, then maybe it'd be worth a call to med control... And I expect they'd just tell you to give the aspirin anyways.

Aspirin is one of the few drugs we have that really truly has a lot of evidence backing it up.  I really don't think we can withhold it because we think maybe we found a zebra.  And really there is barely anything here to point towards dissection.

Maybe someone else can chime in here?  It feels completely insane to me to even consider aortic dissection as an actual possibility, much less let that alter your treatment for this patient given her presentation, history and family history.


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## Clare (Dec 7, 2014)

The balance of risk is in favour of giving aspirin.  

A small dose of aspirin is not going to be clinically significant if the patient has an aortic dissection (now, if we gave thrombolysis then perhaps) but if it's not an aortic dissection but myocardial ischaemia and we don't give aspirin then yes, it would be clinically significant.


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## drl (Dec 7, 2014)

MI symptoms in women often vary from the "classic" presentations we look for--which are typical in men--and can include pain anywhere from the back to the abdomen and shortness of breath.

From an EMT-B level, I'd consider this presentation to most likely be an MI rather than an aortic dissection, especially given family Hx.


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## Brandon O (Dec 8, 2014)

Gurby said:


> Aspirin is one of the few drugs we have that really truly has a lot of evidence backing it up.  I really don't think we can withhold it because we think maybe we found a zebra.



This is a good argument and I might agree (although to be complete we should acknowledge that the benefit of aspirin, while real and well-demonstrated, is not large; around 1 in 40 will benefit).



> And really there is barely anything here to point towards dissection.



Well, older patient with sharp CP radiating to the back, syncope, dyspnea, "head" complaints (i.e. stuff perfused from the aortic arch), unclear but extensive cardiac hx in the family, generally ill-looking and hypertensive. Nothing clear on the 12-lead except some possible inferior ischemia. Nothing convincing but one should wonder.




> It feels completely insane to me to even consider aortic dissection as an actual possibility



This is the one thing I do disagree with. It's our job to consider infrequent but deadly differentials, whether or not we end up disregarding them.


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## mediclife44 (Jan 28, 2015)

Clare said:


> There is an argument that could be made for being guided by automatic interpretation at EMT level however it's not overly strong given the limitations and differences between monitor software
> 
> True...yet in my region, our tx plans (for this scenario) (emt or paramedic) are the same with the exception of pain management. In addition, we have only 1 facility to transport to.


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## mediclife44 (Jan 28, 2015)

Sorry for messing up my last post. Learning curve....


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