# 19 year old chest pain.



## nymedic9999 (Jul 20, 2015)

Who here would give ASA to a 19 year old with unexplained chest pain ( anxiety not suspected)


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## ERDoc (Jul 20, 2015)

Any history of early heart disease?


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## nymedic9999 (Jul 20, 2015)

None known in the family.  Patient is female complaining of pain radiating into her neck.  Vitals were stable.  Pain started while driving.  Pulled over called 911


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## ERDoc (Jul 20, 2015)

Nope, no aspirin.


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## nymedic9999 (Jul 20, 2015)

I just learnt about Reyes syndrome the other day on a call and was wondering.


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## ERDoc (Jul 20, 2015)

Reye's is not really a concern in this pt.  You will rarely see it after 18y/o and the most common age is between 5 and 14.

http://emedicine.medscape.com/article/803683-overview


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## floridamed224 (Jul 20, 2015)

I would give him Aspirin.  It won't hurt him as long as he isn't allergic.  Per protocol where I work:  Call for ALS, Administer Aspirin, Administer Oxygen.  Of course absent any contraindications.


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## COmedic17 (Jul 20, 2015)

It sounds to me like a pulmonary embolism is more likely in a 19 year old female. Probably on BC. PE pain can radiate. Did you put her on capno?


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## Jim37F (Jul 20, 2015)

Legitimately curious, why is 19 years old a contraindication for aspirin?


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## COmedic17 (Jul 20, 2015)

Jim37F said:


> Legitimately curious, why is 19 years old a contraindication for aspirin?


NSAIDS have been linked to higher risk of causing both DVT/PE. A 19 yo female is far more likely to throw a PE  then an MI.


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## Carlos Danger (Jul 20, 2015)

Jim37F said:


> Legitimately curious, why is 19 years old a contraindication for aspirin?


The age isn't a contraindication. Its just that this patient is highly unlikely to be having a CAD event.


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## Tigger (Jul 20, 2015)

futuremed224 said:


> I would give him Aspirin.  It won't hurt him as long as he isn't allergic.  Per protocol where I work:  Call for ALS, Administer Aspirin, Administer Oxygen.  Of course absent any contraindications.


Can't really hurt is very poor justification for treatment.


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## floridamed224 (Jul 20, 2015)

Tigger said:


> Can't really hurt is very poor justification for treatment.



Good thing I didn't say it "Can't really hurt".  I said it won't hurt him.  The age is not a contraindication.


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## medichopeful (Jul 20, 2015)

futuremed224 said:


> I would give him Aspirin.  It won't hurt him as long as he isn't allergic.  Per protocol where I work:  Call for ALS, Administer Aspirin, Administer Oxygen.  Of course absent any contraindications.



Is that the protocol for any chest pain?  Or only of suspected or confirmed cardiac origin?


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## Tigger (Jul 20, 2015)

futuremed224 said:


> Good thing I didn't say it "Can't really hurt".  I said it won't hurt him.  The age is not a contraindication.


Fair enough. So then what's your justification then? Oral glucose won't hurt him either, shall we give that too?

Sure, age is not a contraindication. So what is the indication here?


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## samsbgm (Jul 22, 2015)

nymedic9999 said:


> Who here would give ASA to a 19 year old with unexplained chest pain ( anxiety not suspected)


Hand the 12 lead to your partner first


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## RocketMedic (Jul 25, 2015)

Oddly enough, I recently transported a 17 y/o with a 2mm STEMI in II,III,AvF and a tryponin of 3.43, so it's certainly possible. Unlikely, but that's why we have the fancy magic boxes.


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## DesertMedic66 (Jul 25, 2015)

RocketMedic said:


> Oddly enough, I recently transported a 17 y/o with a 2mm STEMI in II,III,AvF and a tryponin of 3.43, so it's certainly possible. Unlikely, but that's why we have the fancy magic boxes.


Had that exact call during internship


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## EMTinCT (Jul 26, 2015)

http://www.mayoclinic.org/diseases-conditions/costochondritis/basics/definition/con-20024454


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## johnrsemt (Jul 28, 2015)

yes it is unlikely that it is a cardiac event:  but you can't say that for sure: (unless there is a known trauma event leading up to the chest pain {IE base ball to the chest}):  we don't have blood work up in the truck, nor chest x-ray capability:  An ED won't make that decision on a 12 lead only.

Yes it can be a PE, but without a complaint of difficulty breathing or travel, etc then that is hard to make that decision also.

Treat it like it is a cardiac event and transport.  Hate to be the crew that takes a patient into the ED having chest pain that you ignored because they are too young to be having an MI, and find out later that the patient had a MI.


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## ERDoc (Jul 28, 2015)

johnrsemt said:


> yes it is unlikely that it is a cardiac event:  but you can't say that for sure: (unless there is a known trauma event leading up to the chest pain {IE base ball to the chest}):  we don't have blood work up in the truck, nor chest x-ray capability:  An ED won't make that decision on a 12 lead only.
> 
> Yes it can be a PE, but without a complaint of difficulty breathing or travel, etc then that is hard to make that decision also.
> 
> Treat it like it is a cardiac event and transport.  Hate to be the crew that takes a patient into the ED having chest pain that you ignored because they are too young to be having an MI, and find out later that the patient had a MI.



Using that reasoning, this could also be a dissection and I would imagine that you would hate to be the crew that takes a patient into the ED having chest pain that you ignored because they are too young to be having a dissection, and find out later that the patient had a dissection and you gave something that was contraindicated.


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## ViolynEMT (Jul 28, 2015)

COmedic17 said:


> It sounds to me like a pulmonary embolism is more likely in a 19 year old female. Probably on BC. PE pain can radiate. Did you put her on capno?




Especially if she is on birth control pills.


*Edit: I just saw that you had that there. Didn't see it.


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## ViolynEMT (Jul 28, 2015)

EMTinCT said:


> http://www.mayoclinic.org/diseases-conditions/costochondritis/basics/definition/con-20024454




I have actually experienced costochodritis. What I felt was pain when inhaling. It was not a constant pain since it affected the cartilage.


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## cruiseforever (Jul 28, 2015)

I believe you are going to see an increase of MIs in a younger population in the future.  With the improved cardiac care that we have now, people that used to die are now living and passing their genes onto the next generation.


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## WolfmanHarris (Jul 28, 2015)

I had a 24 y/o M c/o 5/10 retrosternal CP radiating bilaterally across the front of his chest, onset while shovelling snow. No history, no known family history, no meds, denied drug use, reported good health in preceding days. Begin my assessment with cardiac not at the top of my list, leaning (reasonably I thought) towards muscular injury given the weight of snow, length of driveway and low risk. Performed a routine 12 lead and got obvious elevation in V1, V2, V3, V4. No evidence of diffuse global elevation, clear unequivocal tracing. Confirm no use of cocaine which Pt. denies adamantly.

Start treatment, package and transport activating the cath lab. Cardiologist meets us, gets report, reviews the ECG; first words "no cocaine?" Goes into the procedure room and talks to the patient ending with: "We are going to do a procedure where I place a wire into your heart. If there is any chance you've taken cocaine, please just tell us so we don't place you at any further risk." Pt still denies. 

100% occlusion LCA. Didn't even stent, Doc did a clotectomy and removed a clot I swear was about the size of my pinky nail (Paramedic fish story?). It was a great lesson to have early in my career for reinforcing thorough assessment and never discounting the possibility of outliers. Sometimes, sometimes, hooves are zebras.


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## Tiger09 (Jul 29, 2015)

ERDoc said:


> Using that reasoning, this could also be a dissection and I would imagine that you would hate to be the crew that takes a patient into the ED having chest pain that you ignored because they are too young to be having a dissection, and find out later that the patient had a dissection and you gave something that was contraindicated.


A dissection is a contraindication for aspirin?


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## DesertMedic66 (Jul 29, 2015)

Tiger09 said:


> A dissection is a contraindication for aspirin?


Anything that stops blood from forming clots would be a contraindication for a dissection


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## Tiger09 (Jul 29, 2015)

DesertMedic66 said:


> Anything that stops blood from forming clots would be a contraindication for a dissection


They should add that in aspirins contraindications


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## DesertMedic66 (Jul 29, 2015)

Tiger09 said:


> They should add that in aspirins contraindications


Hemorrhages is listed as a contraindication in many texts about ASA. 

Also is it really needed? If you know what ASA does (which anyone who is giving it to patients should know) then you should know to not give it to patients who are bleeding or there is a strong suspension of bleeding.


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## Tiger09 (Jul 29, 2015)

I think


DesertMedic66 said:


> Hemorrhages is listed as a contraindication in many texts about ASA.
> 
> Also is it really needed? If you know what ASA does (which anyone who is giving it to patients should know) then you should know to not give it to patients who are bleeding or there is a strong suspension of bleeding.


I think it all depends on the situation.  Obviously 19 y/o chest pain with no other info could be anything.  A dissection could cause an MI, in which you would give aspirin if you didn't suspect a bleed and nitro if they're not hypotensive. And because you treated the MI you made the patient bleed out.  You wouldn't withhold aspirin on a MI because of hypotension right? Every situation is different


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## Tiger09 (Jul 29, 2015)

DesertMedic66 said:


> Hemorrhages is listed as a contraindication in many texts about ASA.
> 
> Also is it really needed? If you know what ASA does (which anyone who is giving it to patients should know) then you should know to not give it to patients who are bleeding or there is a strong suspension of bleeding.


Don't get me wrong though, you do make a great point.  I'm a medic student and it's definitely something I will strongly consider on related calls


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## ERDoc (Jul 29, 2015)

Tiger09 said:


> I think
> 
> I think it all depends on the situation.  Obviously 19 y/o chest pain with no other info could be anything.  A dissection could cause an MI, in which you would give aspirin if you didn't suspect a bleed and nitro if they're not hypotensive. And because you treated the MI you made the patient bleed out.  You wouldn't withhold aspirin on a MI because of hypotension right? Every situation is different


 
You should probably review the reason we give ASA in MIs.  Why would you give it in someone with an MI from a dissection?


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## Tiger09 (Jul 29, 2015)

ERDoc said:


> You should probably review the reason we give ASA in MIs.  Why would you give it in someone with an MI from a dissection?


How would you even know someone is having an MI from a dissection? (Serious question)


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## DesertMedic66 (Jul 29, 2015)

Tiger09 said:


> How would you even know someone is having an MI from a dissection? (Serious question)


12-lead. In the cases where an MI has occurred during a dissection the MIs were from the lack of blood due to the dissection and not because of a blockage (according to the cases I saw on pubmed).


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## ERDoc (Jul 29, 2015)

Tiger09 said:


> How would you even know someone is having an MI from a dissection? (Serious question)



It's all about the history.  Your history will give you 90% of the diagnosis (assuming you ask the right questions) in medical pts.  There is nothing wrong with withholding ASA until you get to the hospital.  Just document why you didn't give it.  I would never give a second thought to a crew NOT giving ASA to an 19y/o with chest pain.  More than likely it is none of the above and something more benign like pleurisy, reflux or stupid.


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## Tiger09 (Jul 30, 2015)

DesertMedic66 said:


> 12-lead. In the cases where an MI has occurred during a dissection the MIs were from the lack of blood due to the dissection and not because of a blockage (according to the cases I saw on pubmed).


But do you know how a 12-lead would present as an MI from loss of blood rather than one from a blockage?


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## cprted (Jul 30, 2015)

I think we need to tidy up a few things, when we're talking dissections, we're not talking about a ruptured aorta and exsanguination, those bleed out long before we get there.  That patient will present in cardiac arrest.  

When we talk about dissection causing MI, we're talking about a Type A dissection that extends into the aortic sinus thus impeding blood flow to the coronary arteries.  

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3354459/


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