# Chest pain before a race



## RedAirplane (Aug 8, 2016)

I was obviously on the BLS side of this but want to better understand that the ALS practitioner does, and why.

*BLS:
*
40 y.o F (athlete) pt presents to aid station before race asking for a blood pressure check because she feels "unusual." The BP turns out to be 160/100.

This reading concerns her. She says that she will not participate in the race, and that this is very concerning, because she manages her blood pressure well despite Hx of HTN and with her meds, she doesn't go above 140 systolic. You confirm she took her HTN meds this morning.

You ask a little more about why she felt the need to come get her BP checked, and she says he is having CP 3/10, localized, but occasionally radiating to the abd in which case it becomes 6/10. With her permission, you do more of an assessment. (-) JVD (-) pedal edema (-) SOB (-) N/V, L/S clear bilat.

PMHx: MI w/ stent, HTN. Pt states this feels like her MI but "not quite as bad" the pain is "slightly less"

ASA withheld per protocol (pt is on blood thinners)

ALS responds Code 3

*ALS:
*
Handoff indicates all of the above. Environment is an increasingly cold and windy marina.

Repeat BP: 190/100, HR 110.

Adminster ASA 324 mg on scene then move into the rig for EKG, then txp Code 2 to cardiac center.

*Questions:
*
For the EMT to understand, what would the big clues to the paramedic be in this case? Give ASA or not? (Possible upside vs downside if the pt is already on blood thinners?)

Code 2 vs Code 3 to the hospital? What treatments to give enroute, if any? I am not in a transport/911 role so some high level understanding of this would be appreciated.

Also, was the systolic BP going up? What does that mean? Or can the error between one reading and another cuff/practitioner be as high as 30 mmHg?

Would you have given NTG? Are you strongly suspecting cardiac, or is your indication to transport purely precautionary?

(Side note: I was extremely happy with the paramedics on this particular call. They were like ducks. Calm and collected above the surface, but vigorous below the surface. Able to hook up the monitor etc while casually conversing with us and the pt, not panicking the patient with eight firefighter/paramedics circling the patient barking questions, but rather having the scribe hovering in earshot secretly jotting everything down, gurney stand back until needed, ambulance parked facing the right direction for patient loading and easy egress... seemed very well thought out from a "how the patient would feel" perspective.)


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## NomadicMedic (Aug 8, 2016)

Glad this went well. This is a typical "bread and butter" chest pain call for ALS. I'll run these all day long. 

The important thing for an ALS provider to see is the 12 lead. And yeah, I'd give the ASA. And, yes... I'd be giving NTG (after a line). With her hx, I'd lean more toward a cardiac incident.


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## RedAirplane (Aug 8, 2016)

DEmedic said:


> Glad this went well. This is a typical "bread and butter" chest pain call for ALS. I'll run these all day long.
> 
> The important thing for an ALS provider to see is the 12 lead. And yeah, I'd give the ASA. And, yes... I'd be giving NTG (after a line). With her hx, I'd lean more toward a cardiac incident.



Are there contradictions for ASA? Or is our protocol just particularly strict?


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## STXmedic (Aug 8, 2016)

RedAirplane said:


> Are there contradictions for ASA? Or is our protocol just particularly strict?


Your protocol is just particularly strict. The biggest contraindication to ASA is allergy.* The most common protocol I see is that you'll give the patient 324mg of ASA when you get there, whether or not they take daily ASA or any other anticoagulant/antiplatelet. The exception to that being if the patient takes 324mg of ASA prior to EMS arrival as instructed by dispatch.

*Others being GI bleeds/ulcers, hemophilia/clotting disorders, and pediatrics.


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## cprted (Aug 8, 2016)

With her history, this is definitely a patient I'd take seriously. Really anyone who tells you this is what my last heart attack felt like, you can put some weight on that finding.  This pt would get ASA, a line, very likely a few sprays of NTG, and serial ECGs.  Also try to rule in/rule out other causes of chest pain as best we can.

Routine transport seems appropriate unless we had some other significant finding, ie. STEMI, pulsating mass in the abdomen, etc ... the time saved (minimal) transporting emerg just isn't worth the increased safety risk in the majority of calls.

Any time anyone tells me they have an MI history, especially a younger person, I try to qualify that a bit.  She had a stent placed, so that puts that one to bed, but there are a lot of people out there, either due to poor medical literacy or misunderstanding will tell you they've had a MI when they haven't. I had a patient that used the term "heart attack" to describe his angina pain.  If you took his story at face value, you might be led to believe that he had had 10+ MIs in the last 3 months. Thankfully his nitro spray "cured" his "heart attack."  What hospital were they seen at, how long did they stay, what interventions were done, are they being followed by a cardiologist? Have a look at their meds, are they on the 'post-MI cocktail?' After an MI, essentially every gets Rx for anticogulation, a beta blocker, often an ACE inhibitor, and a statin.


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## RedAirplane (Aug 8, 2016)

For me the flag was that she didn't want to do the race. That is something I rarely see working a lot of althetlic


DEmedic said:


> Glad this went well. This is a typical "bread and butter" chest pain call for ALS. I'll run these all day long.
> 
> The important thing for an ALS provider to see is the 12 lead. And yeah, I'd give the ASA. And, yes... I'd be giving NTG (after a line). With her hx, I'd lean more toward a cardiac incident.



The 12 lead seems to be the big thing. 

At a couple of events, we dual staff with county paramedic bike teams, who have full ALS equipment except only a 3 lead monitor, no big Lifepak. Purely hypothetical now, but if you were one of those rapid response ALS units, would treatment wait until you got out to the road where there was a real ambulance? Or just play along anyway? My best guess would be ASA but no NTG in case of the type of heart attaxk where NTG is bad... The ones that certain fire departments here got in trouble for. Although I don't understand the details of why that's the case.


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## Tigger (Aug 8, 2016)

RedAirplane said:


> For me the flag was that she didn't want to do the race. That is something I rarely see working a lot of althetlic
> 
> 
> The 12 lead seems to be the big thing.
> ...


Inferior wall MI (especially with right sided involvement) probably shouldn't get NTG, but one would expect them to already be somewhat hypotensive anyway. No absolutes but the odds of a patient having a BP of 190/110 and having an inferior wall MI are unlikely. 

But even then, nitro isn't shown to better outcomes. It's useful to relieve pain, which fentanyl also does without the side effects. ASA should be given to patients on anticoagulants, they work on two separate mechanisms.


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