# Chest Pain



## perimeter (Dec 1, 2013)

You are called to a residence at 2000 hours for a patient experiencing chest pain.


Upon arrival, you enter the residence and find a 73 year old patient laying on his bed in obvious distress.  The pt. is awake and alert.  Describes 9/10 substernal chest pain of sudden onset.  He has a history of triple bypass surgery and took one baby aspirin prior to your arrival.  Pt. doesn't take any other meds regularly.  He is diaphoretic and has a rapid, strong, radial pulse.


He is moved to the stretcher and expediently to the ambulance.  V/S are taken and reveal 122/92, heart rate 160, respirations 16 nonlabored.  Cardiac monitor is placed and V-Tach is shown on the monitor.


Treatment?


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## chaz90 (Dec 1, 2013)

Based on the patients presentation, I'm going to take the time to do a 12 lead EKG first and confirm V Tach as I obtain IV access. I'm also listening to lung sounds to assess possible presence of pulmonary edema. After that, my treatment depends on my findings. Assuming I still believe it is V Tach after I read the 12 lead, I'd try 150 mg IV Amiodarone over ~10 minutes. 

On the surface, this scenario seems fairly straightforward. Are you looking for anything in particular here?


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## Anjel (Dec 1, 2013)

12 lead?

I would put him on o2 via nc... 2lpm would do. IV, bigger the better. I would want a 12 lead, and by the time that is all done, and if the Vtach is really Vtach and sustained I would give Amiodarone 150mg SIVP( that is what is in my box and protocol) over my ten minutes. 

Hopefully he converts, and I can get a better look at what is going on. 

Also priority 1 transport to the nearest ER with cardiac capabilities.

Edit: I totally had mine typed before seeing Chaz's lol


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## perimeter (Dec 1, 2013)

12-lead was not acquired.  Defib pads were placed and IV was attempted unsuccessfully twice.  If you could not obtain IV access, what's your plan?


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## perimeter (Dec 1, 2013)

Pt. was placed on oxygen.  Our protocols state to try valsalva maneuver (I always thought that was just for SVT or narrow complex tachs) but that's what the protocols say.

Out of curiosity, what would a 12-lead show you or would it change your treatment/worth spending the time to do?  Rhythm was monomorphic v tach in II, I, and aVR with a rate 160-180.


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## Anjel (Dec 1, 2013)

I would be very hesitant to cardiovert a stable conscious patient, without an IV if that is what you are getting at. 

I have 5 minute transport times. I would just head off to the ED. If at anytime he became unstable, the defib pads are there and ready for me to use them.

A 12 lead would confirm Vtach. If it's textbook vtach in your 3 lead then ok sure. But by looking at your precordial leads and your axis you can tell a lot more.


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## Akulahawk (Dec 1, 2013)

Given that he's got good BP, my county's EMS protocols basically consider that good enough that he doesn't need immediate cardioversion. Therefore if he's basically stable with they call a "wide complex tachycardia" he'd get 150mg Amiodarone over 10 minutes. If he's not stable, he'd get 150mg Amiodarone IVP and if that doesn't do the trick, sedate with Versed and cardiovert with Max energy... 

So, in other words, if he's hypotensive and has symptoms, spark him. Otherwise do an antiarrythmic and consider cardioversion based on whether the patient is stable or not...

With him, and in my local system, I'd probably start off with an Amiodarone drip (I can speed it up if I need to) and go from there.


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## perimeter (Dec 1, 2013)

Anjel said:


> I would be very hesitant to cardiovert a stable conscious patient, without an IV if that is what you are getting at.
> 
> I have 5 minute transport times. I would just head off to the ED. If at anytime he became unstable, the defib pads are there and ready for me to use them.



That's exactly what I was getting at.  Even if an IV was in place, I wouldn't cardiovert this pt.  He is awake, and alert with a systolic BP over 90.  Obviously without the IV the amio couldn't be given.


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## VFlutter (Dec 1, 2013)

Why no 12 lead? In a patient with cardiac history odds favor VT however a WCT @ 160 is highly suspicious for A flutter with a conduction delay, especially since this patient is not on any antiarrhythmics. Which is probably the main issue here. S/p CABG and no meds? Is he noncompliant?

Transport to the hospital. This guy is fairly stable but may deteriorate quickly. Cardiovert if they become unstable/peri-code. 

You can try valsalva and look for flutter waves.


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## Akulahawk (Dec 1, 2013)

perimeter said:


> 12-lead was not acquired.  Defib pads were placed and IV was attempted unsuccessfully twice.  If you could not obtain IV access, what's your plan?


If I couldn't start a line and I'm sure it's VT... as long as he's alert/conscious and such, I'm going to basically monitor him and transport. If he starts to have a decrease in his level of consciousness and his BP drops off, I'd probably premedicate him with versed IM and spark him. If his BP stays up, I'll do an IO, give him Amiodarone 150 mg IVP, and get ready to proceed down the cardioversion pathway...

The above presumes that I'm working in my local EMS system... and that IV attempts aren't successful and I'm not yet at the point where I'd have to go for an IO...


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## perimeter (Dec 1, 2013)

Chase said:


> Why no 12 lead? In a patient with cardiac history odds favor VT however a WCT @ 160 is highly suspicious for A flutter with a conduction delay, especially since this patient is not on any antiarrhythmics. Which is probably the main issue here. S/p CABG and no meds? Is he noncompliant?
> 
> Transport to the hospital. This guy is fairly stable but may deteriorate quickly. Cardiovert if they become unstable/peri-code.
> 
> You can try valsalva and look for flutter waves.



Yes, non-compliance with Rx meds other than the 81mg aspirin daily.  No 12 lead because I was attempting the IV and as soon as I recognized the VT I had my partner start driving to the ER.  I'm not big on stay-and-play.  I do what I can to the best of my ability while en route to higher care.

Back to the earlier question, if you have what looks like v-tach in a three lead, what are you looking for in a 12-lead that will change your treatment?


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## Aidey (Dec 2, 2013)

perimeter said:


> Back to the earlier question, if you have what looks like v-tach in a three lead, what are you looking for in a 12-lead that will change your treatment?



You are looking for all the signs that allow you to tell V-Tach from some other sort of tachycardia. Differentiating between V-Tach and SVT with aberrancy is important enough to warrant getting a 12 lead. 

This should get you started.


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## Akulahawk (Dec 2, 2013)

perimeter said:


> Yes, non-compliance with Rx meds other than the 81mg aspirin daily.  No 12 lead because I was attempting the IV and as soon as I recognized the VT I had my partner start driving to the ER.  I'm not big on stay-and-play.  I do what I can to the best of my ability while en route to higher care.
> 
> Back to the earlier question, if you have what looks like v-tach in a three lead, what are you looking for in a 12-lead that will change your treatment?


This is one of the patients that I'll sit on scene for a little extra time. I want that 12 lead as it's going to help me determine if it's VT or an SVT. It's also one of those times that I'll want to set myself up for success down the road if I have to spark him, so I'll also do the IV on scene as well. It also allows me to start the Amio drip...

Then, as long as nothing changes, I'll simply transport Code 2 and give him a nice, easy, comfy ride to the ED. No reason to rush or hurry things.


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## teedubbyaw (Dec 2, 2013)

Chase said:


> Why no 12 lead? In a patient with cardiac history odds favor VT however a WCT @ 160 is highly suspicious for A flutter with a conduction delay, especially since this patient is not on any antiarrhythmics. Which is probably the main issue here. S/p CABG and no meds? Is he noncompliant?
> 
> Transport to the hospital. This guy is fairly stable but may deteriorate quickly. Cardiovert if they become unstable/peri-code.
> 
> You can try valsalva and look for flutter waves.



Good post, Chase. That rate had me wondering. 

No IV: you could certainly try a valsalva's maneuver, and if it winds up being aflutter, then there may be a small possibility that it will slow the rate down enough to see what's going on. Otherwise, I would have pads ready and be on standby with additional equipment.


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## TheLocalMedic (Dec 2, 2013)

Aidey said:


> You are looking for all the signs that allow you to tell V-Tach from some other sort of tachycardia. Differentiating between V-Tach and SVT with aberrancy is important enough to warrant getting a 12 lead.
> 
> This should get you started.



^This


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## AEMTstudent (Dec 2, 2013)

ASA?
Nitro?

…..


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## Akulahawk (Dec 2, 2013)

AEMTstudent said:


> ASA?
> Nitro?
> 
> …..


My thinking on this is that the chest pain is primarily caused by the rate he has, which is in the 160's. Control the rate and the chest pain might go away. If it doesn't, then add in the chest pain stuff.


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## AEMTstudent (Dec 2, 2013)

Akulahawk said:


> My thinking on this is that the chest pain is primarily caused by the rate he has, which is in the 160's. Control the rate and the chest pain might go away. If it doesn't, then add in the chest pain stuff.



That's a very good possibility.  Is the ST elevated? Any alteration in the Q wave?  What do we see on the 12 lead?


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## teedubbyaw (Dec 2, 2013)

Vtach will most always obscure ST segment changes. Best plan of action is rate control if anything.


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## Handsome Robb (Dec 2, 2013)

AEMTstudent said:


> That's a very good possibility.  Is the ST elevated? Any alteration in the Q wave?  What do we see on the 12 lead?



I'm gonna go out on a limb and say you didn't read the whole thread...

Everyone has already covered it pretty well. With a patient like this you bet I'm sitting on scene and getting things done before we go anywhere. 

If we can't get a line we can't get a line. I'd look for an EJ. I would not drill this guy unless I had to. While VT is a lethal arrhythmia people can sustain it for long periods of time (read: hours if not days). If his MAP stays solid and he stays "stable" I've got no problem waiting for the ER to try and get access with some of their tools before popping this guy with an IO. 

Also be transporting non-emergent as well unless he decided that he wanted to dance on the way to the hospital. 

What would it change if you suspected A-flutter with a conduction delay or SVT with aberrancy?


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## AEMTstudent (Dec 2, 2013)

Robb said:


> I'm gonna go out on a limb and say you didn't read the whole thread...
> 
> Everyone has already covered it pretty well. With a patient like this you bet I'm sitting on scene and getting things done before we go anywhere.
> 
> ...




Agreed. I read the first post and discarded the rest.  

Wouldn't you be cardioverting for this?  I could be way off here, enlighten me.


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## Handsome Robb (Dec 2, 2013)

AEMTstudent said:


> Agreed. I read the first post and discarded the rest.
> 
> Wouldn't you be cardioverting for this?  I could be way off here, enlighten me.



I've got no way to sedate him unless I go IM or IN and the former wouldn't kick in until we were giving our handoff report in my system and the latter isn't all that effective. It's a painful procedure and is malpractice to cardiovert an awake and oriented patient who's hemodynamically stable.

He's not sick enough to warrant me drilling into his bone. Some will argue he has potential to deteriorate but my argument is if he does an IO takes literally 10 seconds so I'm not worried about that. Plus if this guy goes to hell in a handbasket on me the first placing I'm reaching is to the monitor to zap him not for drugs. 

The hospital has tools (ie ultrasound) they can use as well as a controlled environment. I'd rather transport him the way he is and let them find access and provide the appropriate therapy than cause him a lot of discomfort and administer a therapy that isn't indicated.

EMS education teaches that everyone in VT is going to die right her right now. Yea it's a lethal dysrhythmia but it is one that many can maintain for hours if not >24 hours. 

Also, if I don't fix the underlying problem the dysrhythmia is just going to come back. Why not let the ERP and cardiology mull it over and get it right the first time?


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## AEMTstudent (Dec 2, 2013)

I've heard of adenosine use being very painful and shocks i'm guessing would be equally sucky. Would you consider metoprolol for the aflutter? 
Thanks for the clarification.


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## Handsome Robb (Dec 2, 2013)

AEMTstudent said:


> I've heard of adenosine use being very painful and shocks i'm guessing would be equally sucky. Would you consider metoprolol for the aflutter?
> Thanks for the clarification.



If this is VT I'd use amiodarone over adenosine personally. Lidocaine would be an option to as well as procainamide. Amiodarone doesn't have the nasty "I'm going to die" feeling side effects that adenosine does. 

FWIW my protocol is either transport or cardiovert for A-flutter.

If it were A-flutter I'd prefer to use a CCB like diltiazem to slow the rate in a prehospital setting. You could use amiodarone too but then you have the potential to actually convert to a sinus rhythm and have potential for clots being kicked from the atria as a result of blood pooling from ineffective atrial emptying. 

If you gave adenosine to an a flutter patient it won't hurt them, it's not uncommon for it to happen, have a transient slowing of the ventricular response to allow flutter waves to be identified and then change treatment pathways.


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## Akulahawk (Dec 2, 2013)

AEMTstudent said:


> I've heard of adenosine use being very painful and shocks i'm guessing would be equally sucky. Would you consider metoprolol for the aflutter?
> Thanks for the clarification.


Like Robb, I would prefer diltiazem for rate control over metoprolol in A-flutter. Adenosine doesn't hurt, it causes the patient's heart to slow or even stop, which is what makes the patients really not like the stuff... but it might slow the heart enough to be able to see the underlying rhythm.


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## AEMTstudent (Dec 2, 2013)

Akulahawk said:


> Like Robb, I would prefer diltiazem for rate control over metoprolol in A-flutter. Adenosine doesn't hurt, it causes the patient's heart to slow or even stop, which is what makes the patients really not like the stuff... but it might slow the heart enough to be able to see the underlying rhythm.



This is good information to know.  I just checked our drug file and we don't carry dilitazem.


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