# chest pain scenario



## trauma1534 (Nov 26, 2006)

You have a 59 yom patient.  He has been experiencing crushing chest pains for the last hour.  Pain is radiating down his left arm, and he is now vomiting, sweating perfusly, and just plane out looking crappy.  

Allergies:  PCN
Medications:  Nitro SL/PRN, ASA 81mg
Past Medical Hx:  He has had some bouts with chest pain before, so his doctor gave him some Nitro, and he takes ASA on his own, has for years.  Otherwise, pretty healthy 59 yo.
Last oral intake:  2 hours ago, ceriel and toast with milk

Before this chest pain started, he was just setting in his chair, watching his dog play with a bone, had been since he ate.

The only thing he said was that he did take a pill last night.  He has not taken any Nitro yet.  He actually forgot about it, till EMS showed up and started asking about his medications.  

B/P:  160/78   Resp:  26    HR:  102   Pain on a ten scale:  9  O2 Sats:  92%

What would you do?


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## jeepmedic (Nov 26, 2006)

Press hard 2 copy's. He can drive.


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## trauma1534 (Nov 26, 2006)

jeepmedic said:


> Press hard 2 copy's. He can drive.



Geeze!  You had to give it away so soon?  lol

No really people, this is a good scenario, and one to learn from!  Help me out here Jeep!  LOL


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## jeepmedic (Nov 26, 2006)

trauma1534 said:


> Geeze!  You had to give it away so soon?  lol
> 
> No really people, this is a good scenario, and one to learn from!  Help me out here Jeep!  LOL





I'll never tell


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## trauma1534 (Nov 26, 2006)

You better not!!!  ;-p


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## Medivixen (Nov 27, 2006)

Follow local protocol...that is why they are there.
My protocol is as follows:

High flow O2 via NRB
nitro 0.4mg SL
transport code 4 with ALS intercept if available
ASA 81mg x 2 chewed
vitals 
if bp is over 100 systolic and pain still persists 2 more doses of nitro 5 mins apart
after 3rd dose stop wait 5 mins and give Entonox if not contraindicated
position of comfort


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## FFEMT1764 (Nov 27, 2006)

IV, O2, monitor, 12 lead, NTG x3 SL spray provided BP >90 systolic. ASA 243 mg (he's already had 81 mg in the past 12 hours). If no pain relief after NTG call for orders for morphine 2-10 mg titrated to effect. Any further treatment would then be based on the next set of vitals and what the 12 lead shows. And yes, transport to the chest pain center.


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## trauma1534 (Nov 27, 2006)

That's all well and good, but you guys have probably just killed your patient!  Aren't you the least bit interested in what that pill was that he took last night?  And how long it had been since "last night" when he took it?


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## ndilley (Nov 27, 2006)

could that "pill from last night" be something along the lines of viagra, in which spraying him full of nitro would make his blood pressure hit the floor? in which case follow the o2, monitor, iv, asa, protocol and just skip the nitro


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## Epi-do (Nov 27, 2006)

1.  Request ALS, if not already enroute

2.  High flow O2, 15 lpm via NRB

3.  2 - 81 mg baby ASA

4.  Make sure he hasn't taken any viagra, levitra, etc.

5.  Assist with patient's nitro only if the pill wasn't anything mentioned above.  (If it was viagra, levitra, etc, then just load and go.)

6.  Load and go (hopefully meeting ALS)

7.  Only if no viagra, reassess VS, as long as BP remains above 110 systolically, repeat nitro up to a total of 3 doses.  If ALS isn't available, and after 3 doses patient is still complaining of pain, contact receiving facility for orders to administer additional nitro (again, after reassessing BP).


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## trauma1534 (Nov 27, 2006)

ndilley said:


> could that "pill from last night" be something along the lines of viagra, in which spraying him full of nitro would make his blood pressure hit the floor? in which case follow the o2, monitor, iv, asa, protocol and just skip the nitro



You are exactly right!  It was viagra!


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## FFEMT1764 (Nov 27, 2006)

In my experience most people on viagra tell you they are when the are having chest pain, they all have watched the TV and know that NTG and Viagra and etc can cause profound hypotension. The hypotension, if treated agressively, can be reversed, but it does take several hours, and lots of treatment.  Good practice- always have the patient show you all the pill bottles for every med they take prior to giving them ANY medication other than oxygen...lots of drugs have interactions that can be bad, not just NTG and Viagra.


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## Airwaygoddess (Nov 27, 2006)

Lets hear it for a good SAMPLE hx and protocals!!^_^ :beerchug:


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## trauma1534 (Nov 27, 2006)

FFEMT1764 said:


> In my experience most people on viagra tell you they are when the are having chest pain, they all have watched the TV and know that NTG and Viagra and etc can cause profound hypotension. The hypotension, if treated agressively, can be reversed, but it does take several hours, and lots of treatment.  Good practice- always have the patient show you all the pill bottles for every med they take prior to giving them ANY medication other than oxygen...lots of drugs have interactions that can be bad, not just NTG and Viagra.



This guy had been given this pill from a friend.  He did not know the exact name of it or the interaction with NTG.  

Like you said, that's why it is important to fish around and look at the whole picture.  Don't get in the narrow minded practice that because it is chest pain you must give NTG if the B/P is above 100 systalic.  Think outside the box.  

While knowing that hypotention can be treated aggresivly and corrected over a period of time, don't give NTG if your patient has taken Viagra or like drugs.  You are opening yourself up for problems that may not be corrected in time.  

Think outside the box in every situation, even if it is a granny toat from the nursing home to the ER for a stomach ache that has lasted 4 days and now this nursing shift decides that they want to have this granny taken to the ER.  Dig deep and find why the patient is having the problem.  If they are unresponsive with no known drug abuse history, look at thier meds, count them when you get the chance, even if it is after you place the patient on the stretcher in the ER.  Don't get stuck in tunnel vision, as we all have at one time or another.  As soon as you get in the tunnel vision mind frame, it will bite you!


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## Airwaygoddess (Nov 27, 2006)

Forget the fishing, this comes under digging!!^_^


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## Medivixen (Nov 27, 2006)

We should all be in the practice of not giving a drug to a patient without checking the indications and contraindications first. Period..


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## FFEMT1764 (Nov 28, 2006)

Around here people also develop hurry up get me in the back of the ER chest pain too, secondary to a tooth ache, hang nail, or finger cut, and as such the get the new pain drug Nachel (NaCl)...strangely enough the chest pain goes away...of course I treat true chest pain appropriately...I just have fun with the seekers...


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## grammarose (Dec 31, 2006)

*C.p*

Besides being an EMT, I sometimes work in the Emergency Room at our hospital. I recently had this patient walk in off the street with Chest Pain. I sat him in a wheelchair to take him to the Emergency room. I started asking questions, to see if it traveled anywhere, weather he was short of breath. He said it traveled to his shoulder, and he was short of breath at times. He said he knew what it was because he had this 30 years ago and it was indegestion. He also went hunting through the day. He had pain for two days. We get him hooked up to the monitor, did blood work and found out he actually id have an MI.


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## soon2bemt (Dec 31, 2006)

trauma1534 said:


> You have a 59 yom patient.  He has been experiencing crushing chest pains for the last hour.  Pain is radiating down his left arm, and he is now vomiting, sweating perfusly, and just plane out looking crappy.
> 
> Allergies:  PCN
> Medications:  Nitro SL/PRN, ASA 81mg
> ...



Even if pt had taken Viagra, I would still consider the Nitro due to pressure being 160/78.  I actually had a similar case to this one.  Pt. had taken Viagra and had Nitro pills of his own.  B/P was 168/90, pulse of 146, respirations of 24.  I contacted medical control-told him the situation, all the pt's information and vitals and he said go ahead with 1 and only 1 Nitro.  I did so-put him on 02 at 15 lpm-and hauled butt to the hospital due to him being sweaty, pain scale of 9, looking crappy, and radiation to the left arm.  My partner did all of her ALS stuff-cept for the Nitro pill that I "assisted" with.  She was busy trying to hook up the 12-lead-which by the way this guy we had was in V-Tach......my partner said that is the first time she had ever seen perfusing V-Tach.....SCARY!

Now, if I was on a BLS truck I would seriously consider flying this patient to a cardiac center-could get them to a hospital faster than we could either get an ALS unit to us or get the pt to a hospital.


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## Jersey (Jan 1, 2007)

Medivixen said:


> Follow local protocol...that is why they are there.
> My protocol is as follows:
> 
> High flow O2 via NRB
> ...



I've never used entonox. Can someone describe this drug to me?

Thanks!
Matt


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## Medivixen (Jan 21, 2007)

*Entonox = Nitrous Oxide*

here's a little something from my monographs.  We can admin entonox for pain prn... pretty basic stuff; our first responders can get an endorsement for it even.  Handy!


*NITROUS OXIDE (ENTONOX)*

*Classification* - An inorganic compound made of ammonium nitrate. Analgesic.

*Mechanism* - Inhalation of a 50% mixture of Nitrous Oxide and oxygen produces CNS depression as well as rapid pain relief (Pharmacology for Prehospital Emergency Care, pp. 127-8). 
Analgesic working specifically on the central nervous system (Pharmacology in Nursing, p. 305).


Indications:
• Relief of moderate to severe pain from any cause:
 acute myocardial infarction
 musculoskeletal trauma
 burns
 other conditions (e.g., ureteral colic, labour)

Contraindications:
• Any altered level of consciousness such as head injury (masks neurologic signs one needs to monitor)
• Acute pulmonary edema (these patients require 100% oxygen)
• Known pneumothorax or chest injury (Nitrous Oxide collects in dead air spaces)
• Decompression sickness
• Air embolism
• Cyanosis develops during administration
• Inability to ventilate an enclosed treatment area (e.g. air transportation)
• Patient has taken Nitroglycerin within the last 5 minutes
• Inhalation injury

Cautions:
• Abdominal distension (absent bowel sounds)
• Shock
• Chronic obstructive pulmonary disease
• Major facial trauma
• Patient has taken a depressant drug
• Improper storage
 Low temperature (NOTE: storage below -6 degrees C: gas will separate.
[ref. EMA I Update: Entonox Protocol, Paramedic Academy, 1993])
 Stagnant
 Vertical position
• Combustion/inhalation/dependence

Dose:
• Self-administered. As the patient becomes drowsy, the mask / mouthpiece will drop away from the patient's mouth / face.
• Patient controlled until pain is relieved.

ADVERSE AFFECTS - There are nine common adverse affects in the use of Entonox:
• aggravation of middle ear (increases pressure)
• drowsiness
• nausea
• vomiting
• giddiness
• dizziness
• amnesia
• decreased level of consciousness
• decreased cardiac output



And if for nothing else, you can inject it into the cylinders of the engine of your bus and really jam your patients to the ER and set a golden hour speed record at the same time!


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## slallak (Jan 25, 2007)

if his BP is really that high (160/78) and he took the pill (lets say it was viagra) last night go ahead and give him the nitro. You are going to call for als back before that I hope. I would have. His BP is high enough that it probably wont hurt. Then load and go.


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## Ridryder911 (Jan 25, 2007)

It's obvious most of you have never seen NTG effects on Viagra, or even right side infarcts. What are you going to do when their pressure drops to 60/20 ? If a physician orders it, then the are taking the risks.

Congrat's you just increased the infarct size..!

R/r 911


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## yowzer (Jan 26, 2007)

Ridryder911 said:


> It's obvious most of you have never seen NTG effects on Viagra, or even right side infarcts. What are you going to do when their pressure drops to 60/20 ? If a physician orders it, then the are taking the risks.
> 
> Congrat's you just increased the infarct size..!
> 
> R/r 911



Plenty of people have little bottles of ntg tabs to take when they get an angina attack or other chest pain. They're not doing 12-leads on themselves to look for a right-sided MI first (Or even taking a blood pressure.)

Is it a rare enough site for an MI that the risks are worth the benefits for nitro in general?


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## Ridryder911 (Jan 26, 2007)

Really no. They are studing the number of induced or enlargement of AMI's caused by NTG. That is why discussion of possibly removing NTG from basic EMT criteria if the patient does not have previous hx. of angina or if the patient has not been treated previously with NTG.  

Not only right side side infarcts but some lateral and posterior wall as well as progressive transmural infarcts have been increased with the effects of NTG. 

Remember, there is a difference from angina, and AMI. The problem is differentiating the two. 

True, NTG may not always increase or even effect a ride sided AMI. But, again the would you want to be on the side of the roll of the dice ? 

Personally, my medical director no longer wants NTG administered until inferior wall is cleared. You will see more and more of this as research continues. 

Nitroglycerin is a wonderful drug/medication but like any other it has side effects and should only be used with  appropriate  indications. The treatment of angina as determined by a thorough an accurate history and physical exam and other conditions have been ruled out. 

I have been on more than several calls with syncopal episodes from administration of NTG. As well have seen hypotensive episodes from NTG. Remember what occurs in hypotension, as the baroreceptors sense low volumes. Heart rate increases as well as contraction strength, which causes an increase work load on the heart. Thus increasing a larger AMI. 

Of course until new standards comes out we will continue to perform as instructed and currently taught, just a "heads-up" on the potential changes in a couple of years. 

R/r 911


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