ACS questioning.

[jdemt]

I’m looking for a better way to differentiate cardiac chest pain from non-cardiac.

At this point I’m first looking at the patient for skin color and diaphoresis.

After that I palpate their sternum to see if that elicits pain, and ask questions based on you’re typical OPQRST.

Finally I put them on the 12-lead and analyze.

Right now, my mindset is to have (as Williamson county MD says) a good 12-lead and a good story.

In other words I’m looking for a relatively rapid onset, nausea, SOB, diaphoresis, non-reproducible chest pain, not made better with rest, etc. Its a little haphazard, and I find myself giving ASA even when I’ve ruled out ACS (as far as I am able). I really want to get away from the mindset of “I’ll give aspirin just in case”.

Are there some other questions/assessments I can do to make my treatment plan more concrete?

Thanks!

 

[VentMonkey]

Experience, experience, experience...

...and even then our differentials are never a 100% for sure thing. Giving ASA “just in case” doesn’t make you anything short of prudent.

Do I give ASA to every single CP patient still? No, not anymore, but again time and experience will help you evolve.

While I understand and appreciate the new day and age where we can literally go on the internet and ask complete strangers with more experience “what would you do?”, I can’t imagine the provider I would have become had I never learned things on my own.

We’re short-term providers. The best I can do many times, even at my level of EMS training and field experience, is to be proactive with learning by any and all means necessary. Sometimes it does in fact include peer review, and/ or Q & A. A lot of the times it’s self-driven research outside of this forum.

 

[cprted]

The reality is, a lot of the history findings that we have historically been taught to hang our hats on in the rule in/rule out of ACS have very poor sensitivity and specificity. In my own practice, I keep a high index of suspicion for ACS. The so-called "classic anginal chest pain presentation" only occurs in maybe 30-40% of people presenting with ACS.

What is the risk:benefit profile for ASA? Unless I can clearly attribute their CP to some other cause, ASA is a pretty non-invasive and low risk treatment.

Just my 1.6 cents (the exchange rate is awful right now).

 

[medichopeful]

I would get a 12-lead earlier. You're going to touch their skin when you do that, so you'll get that information then. Ask questions while you apply the stickers, then analyze the 12-lead.

There are no questions you can ask or exams that you can do to 100% rule in or rule out a cardiac issue (with a few exceptions) in the field. Keep that in mind. When in doubt, treat it as cardiac.

Also, reproducible chest pain, while an important piece of information, shouldn't be a deciding factor one way or the other!

 

[mgr22]

Jdemt, I agree with the other comments, and will just add that there's a common-sense side to assessment that complements the medical side. The common-sense part is more about being curious than diagnosing a medical condition. For example:

What's going on?
What does it feel like?
Have you had it before? If so, is there anything different about it?
Do you take anything for it?
Have you seen a doctor for it? If so, what did he/she call it? What did he/she do?
Does anything help?

I was asking family members these questions before I knew anything about medicine.

 

[Alan L Serve]

EKG the moment you get there. Repeat it every 10-20 minutes while the PT is in your care. I've seen a totally normal 12 lead in a highly symptomatic patient then 10 minutes later a repeat 12 lead showed STEMI in the inferior leads.

 

[Aprz]

Gosh, I hate talking about this, because I feel like I am very different from a lot of paramedics. I always feel like I find out I am an idiot this way, lol.

So anyways, I rarely give aspirin and nitroglycerin. The only time I really give it is if they have typica chest pain vs atypical chest pain patients that are generally age appropriate (think like >30-35 years old, I don't have an arbitrary number I use, I guess it is just my mood) and, of course, STEMI patients. I think that the mindset of chest pain patients get aspirin is somewhat good, but also somewhat unusual. With chest pain AND ST changes, one study showed that only 16-17% of patients were having a STEMI (@Brandon O, I believe this study from your website a million years ago, but I don't remember your website to link it). Interesting, right? While we consider chest pain to be a common sign of MIs, maybe seen in the majority (doesn't honestly match my own experience), that doesn't mean it happens more than 50% of the time. In fact, I've seen a lot more STEMI patients with only shortness of breath, some who had anxiety (one said she was having a panic attack for 2 days before she called 9-1-1, her 12-lead, if I recall right, showed an inferior wall MI), "I feel funny", neck pain for 2-3 days (this one wasn't my own patient, but the 12-lead was shown to me, he had a proximal LAD occlusion that showed ST elevation in V1-4 with a RBBB, the patient went into cardiac arrest in the cath lab), nausea, generalized weakness, skin changes, etc... A lot of these symptoms we don't just give aspirin without discrimination, yet chest pain is a special one to us I guess?

Anyways, when I suspect the call may be ACS, I'll have my partner apply the 12-lead while I ask OPQRST questions.

O - What were doing when this started? Did they wake up with it?
P - Is there anything that makes it better or worse? If I push on it, does that change it (so weird how some people feel better when I push on their chest??? LOL I have magic healing powers)? If the patient self administered a nitroglycerin tablet or I did, did that change it? If they lay down, does that change it (pericarditis is associated with increased pain while laying down since the heart doesn't actually sit still in the mediastinum like most people image)?
Q - What does it a feel like? I always feel like this patients always say "I don't know! It just hurts!" and I break the rule by giving them examples "Cramping, sharp, stabbing, tearing?"
R - Show me where the pain is at. There was a study on how patients make hand motion pointing to their (chest) pain, and this is associated with the likeliness of it being cardiac/ACS/STEMI. Pointing into a single spot was associated with a low chance of cardiac/ACS/STEMI while with an open hand going over the chest increased the likelihood that it was maybe actually cardiac. Sometimes, I'll be blatant, and I ask "Is it on the left side or right side of your chest?" to help them understand the question. Okay, where does the pain go to? Your arm? Neck? Back? Tummy?
S - Of course the 1-10 question. As you evaluate change in pain, you want to reuse this eg after giving nitro, after palpating the chest, when changing the position's position.
T- When did this start? Give me a time please; It doesn't have to be the exact time, just give me a general time. Did it start hours ago? If this started awhile ago, why did you wait until now to call?

As a part of S/S in SAMPLE, I don't limit myself to one set of questions or have to use a mneumonic, so I'll ask other things like do you have any shortness of breath? Nausea? Dizziness? Weakness? Some things that make me think less likely cardiac is if they have a cough, pain gets worse when coughing, rhonchi, pneumonia, and diarrhea, so I ask those when it makes sense.

I also typically ask (with most medical complaints) has this happened before? Did you go to the hospital for it? What did they say it was? Have you ever had any heart problems? Do your family have any heart problems? This is a good time to mentally collect if the patient has things that can be contributing factors like hypertension, heart failure, diabetes, cardiac dysrrhythmia, pacemaker, if they take any anticoagulant, high cholesterol, and previous clotting problems. Consider medications like hypertension medications, dysrhythmia medications, diabetes, neuropathy, angicoagulant, or birth control/hormone medications.

Overall, you are going to have to take the overall picture of the patient, brush up on ECG/12-lead skills (not being worried that maybe there is a hidden MI in the 12-lead will make you feel more confident vs if you are like axis???? Posterior Wall MI??? What are those big R waves???? :?), consider "serial 12-lead" (do a repeat 12-lead with vital signs every 10-20 minutes (you can feel more confident in not giving aspirin/nitroglycerin when the 12-lead comes out the same each time). Also, if you do give the patient aspirin and nitro when there is contraindication (patient isn't allergic to it, nothing weird like the Samter's triad, no hypertension, not taking any ED medications including ladies with pulmonary hypertension), I don't think anyone is going to fault you for aggressively treating chest pain. In some cases, because nitroglycerin is a smooth muscle relaxer, the patient will experience some pain relief anyways (remember, pain relief from nitroglycerin does not mean it is cardiac, and atypical chest pain does not mean it is not cardiac either). In the end, just go with your gut feeling. You will figure it out with experience I guess. I think it is also going to depend on how involved your medical directors are and CES department. Like for me, I haven't gotten any negative feedback from them (kind of common in EMS tbh), so I have gotten a lot more lax about not giving aspirin/nitro.

 

[Brandon O]

l. With chest pain AND ST changes, one study showed that only 16-17% of patients were having a STEMI (@Brandon O, I believe this study from your website a million years ago, but I don't remember your website to link it).

http://emsbasics.com/2012/10/26/managing-stemi-mimics-in-the-prehospital-environment-video-lecture/

I agree that being really good at recognizing ischemia on the ECG, even with subtle or hidden manifestations, is the tool that will get you the furthest here. If the patient presentation isn't too impressive and the ECG looks okay to your expert eye, you can feel pretty good about taking it easy.

 

[DrParasite]

So I recently completed my cardiac EMS con ed.... here is what I learned:

1) have the person use 1 finger, and point to where the pain is.
2) if it's more abdominal, ask if they have eaten anything spicy, or tomato based. If they have, ask them if they have taken any Tums
3) Nitro saves lives. If they have a clot, which is causing chest pain, them getting nitro can widen the arteries to let the clot pass.
4) if the person has had a heart attack previously, and describes the pain as exactly as it was last time, it's probably not cardiac related. It's generally just anxiety, which is causing their vitals signs to get worse.
5) If you break a rib, the biggest concern is that rib might pierce the diaphragm. Sidenote: compressions don't break ribs, just the cartilage that connects the ribs to the sternum.
6) fast and hard compressions are not a sign of good CPR.

Just thought I would share.

 

[jdemt]

Gosh, I hate talking about this, because I feel like I am very different from a lot of paramedics. I always feel like I find out I am an idiot this way, lol.

So anyways, I rarely give aspirin and nitroglycerin. The only time I really give it is if they have typica chest pain vs atypical chest pain patients that are generally age appropriate (think like >30-35 years old, I don't have an arbitrary number I use, I guess it is just my mood) and, of course, STEMI patients. I think that the mindset of chest pain patients get aspirin is somewhat good, but also somewhat unusual. With chest pain AND ST changes, one study showed that only 16-17% of patients were having a STEMI (@Brandon O, I believe this study from your website a million years ago, but I don't remember your website to link it). Interesting, right? While we consider chest pain to be a common sign of MIs, maybe seen in the majority (doesn't honestly match my own experience), that doesn't mean it happens more than 50% of the time. In fact, I've seen a lot more STEMI patients with only shortness of breath, some who had anxiety (one said she was having a panic attack for 2 days before she called 9-1-1, her 12-lead, if I recall right, showed an inferior wall MI), "I feel funny", neck pain for 2-3 days (this one wasn't my own patient, but the 12-lead was shown to me, he had a proximal LAD occlusion that showed ST elevation in V1-4 with a RBBB, the patient went into cardiac arrest in the cath lab), nausea, generalized weakness, skin changes, etc... A lot of these symptoms we don't just give aspirin without discrimination, yet chest pain is a special one to us I guess?

Anyways, when I suspect the call may be ACS, I'll have my partner apply the 12-lead while I ask OPQRST questions.

O - What were doing when this started? Did they wake up with it?
P - Is there anything that makes it better or worse? If I push on it, does that change it (so weird how some people feel better when I push on their chest??? LOL I have magic healing powers)? If the patient self administered a nitroglycerin tablet or I did, did that change it? If they lay down, does that change it (pericarditis is associated with increased pain while laying down since the heart doesn't actually sit still in the mediastinum like most people image)?
Q - What does it a feel like? I always feel like this patients always say "I don't know! It just hurts!" and I break the rule by giving them examples "Cramping, sharp, stabbing, tearing?"
R - Show me where the pain is at. There was a study on how patients make hand motion pointing to their (chest) pain, and this is associated with the likeliness of it being cardiac/ACS/STEMI. Pointing into a single spot was associated with a low chance of cardiac/ACS/STEMI while with an open hand going over the chest increased the likelihood that it was maybe actually cardiac. Sometimes, I'll be blatant, and I ask "Is it on the left side or right side of your chest?" to help them understand the question. Okay, where does the pain go to? Your arm? Neck? Back? Tummy?
S - Of course the 1-10 question. As you evaluate change in pain, you want to reuse this eg after giving nitro, after palpating the chest, when changing the position's position.
T- When did this start? Give me a time please; It doesn't have to be the exact time, just give me a general time. Did it start hours ago? If this started awhile ago, why did you wait until now to call?

As a part of S/S in SAMPLE, I don't limit myself to one set of questions or have to use a mneumonic, so I'll ask other things like do you have any shortness of breath? Nausea? Dizziness? Weakness? Some things that make me think less likely cardiac is if they have a cough, pain gets worse when coughing, rhonchi, pneumonia, and diarrhea, so I ask those when it makes sense.

I also typically ask (with most medical complaints) has this happened before? Did you go to the hospital for it? What did they say it was? Have you ever had any heart problems? Do your family have any heart problems? This is a good time to mentally collect if the patient has things that can be contributing factors like hypertension, heart failure, diabetes, cardiac dysrrhythmia, pacemaker, if they take any anticoagulant, high cholesterol, and previous clotting problems. Consider medications like hypertension medications, dysrhythmia medications, diabetes, neuropathy, angicoagulant, or birth control/hormone medications.

Overall, you are going to have to take the overall picture of the patient, brush up on ECG/12-lead skills (not being worried that maybe there is a hidden MI in the 12-lead will make you feel more confident vs if you are like axis???? Posterior Wall MI??? What are those big R waves???? :?), consider "serial 12-lead" (do a repeat 12-lead with vital signs every 10-20 minutes (you can feel more confident in not giving aspirin/nitroglycerin when the 12-lead comes out the same each time). Also, if you do give the patient aspirin and nitro when there is contraindication (patient isn't allergic to it, nothing weird like the Samter's triad, no hypertension, not taking any ED medications including ladies with pulmonary hypertension), I don't think anyone is going to fault you for aggressively treating chest pain. In some cases, because nitroglycerin is a smooth muscle relaxer, the patient will experience some pain relief anyways (remember, pain relief from nitroglycerin does not mean it is cardiac, and atypical chest pain does not mean it is not cardiac either). In the end, just go with your gut feeling. You will figure it out with experience I guess. I think it is also going to depend on how involved your medical directors are and CES department. Like for me, I haven't gotten any negative feedback from them (kind of common in EMS tbh), so I have gotten a lot more lax about not giving aspirin/nitro.

Thank you so much! This was super helpful. Currently my agency doesn’t give nitro for chest pain (Not part of the flow chart) but we don’t have protocols, (instead we have “guidelines”)so it can still be part of the treatment plan if indicated. I know exactly what you’re saying about EKGs, I really need more work on some of the less obvious stuff. Sure wish I had healing powers! Haha

 

[jdemt]

So I recently completed my cardiac EMS con ed.... here is what I learned:

1) have the person use 1 finger, and point to where the pain is.
2) if it's more abdominal, ask if they have eaten anything spicy, or tomato based. If they have, ask them if they have taken any Tums
3) Nitro saves lives. If they have a clot, which is causing chest pain, them getting nitro can widen the arteries to let the clot pass.
4) if the person has had a heart attack previously, and describes the pain as exactly as it was last time, it's probably not cardiac related. It's generally just anxiety, which is causing their vitals signs to get worse.
5) If you break a rib, the biggest concern is that rib might pierce the diaphragm. Sidenote: compressions don't break ribs, just the cartilage that connects the ribs to the sternum.
6) fast and hard compressions are not a sign of good CPR.

Just thought I would share.

Thanks! I’ll have to read more about nitro.!Our current medical directors say there is minimal evidence that nitro is helpful in cardiac patients. We can still give it if we feel it is necessary, and of course we have it for pulmonary/cardiac pulmonary edema. It was hard to get used to not giving nitro since the last agency I worked for required it almost every chest pain call.

 

[DrParasite]

Thanks! I’ll have to read more about nitro.!Our current medical directors say there is minimal evidence that nitro is helpful in cardiac patients.

I'd be inclined to agree with what your medical director says..... The instructor who provided that information has provided some..... questionable information in the past, some that runs directly contrary to my experience and contract to what some smart people have told me.

Last I checked, the science doesn't back up her statement about Nitro.

We can still give it if we feel it is necessary, and of course we have it for pulmonary/cardiac pulmonary edema. It was hard to get used to not giving nitro since the last agency I worked for required it almost every chest pain call.

True fact: in my state, according to state protocols, EMTs can give NTG for pulmonary edema without a medic present or a 12 lead, provided the patient has a prescription for it

 

[jdemt]

True fact: in my state, according to state protocols, EMTs can give NTG for pulmonary edema without a medic present or a 12 lead, provided the patient has a prescription for it[/QUOTE]

Hmmm....perhaps we are in the same state. It’s a patient assist here too.

 

[jdemt]

Sorry forgot to add the other quote thing.

 

[Brandon O]

So I recently completed my cardiac EMS con ed.... here is what I learned:

2) if it's more abdominal, ask if they have eaten anything spicy, or tomato based. If they have, ask them if they have taken any Tums

I would NOT be using this sort of thing to rule out coronary ischemia. Spicy food is not cardioprotective.

3) Nitro saves lives. If they have a clot, which is causing chest pain, them getting nitro can widen the arteries to let the clot pass.

This is not right. Nitro has not been clearly shown to improve outcomes in ACS.

4) if the person has had a heart attack previously, and describes the pain as exactly as it was last time, it's probably not cardiac related. It's generally just anxiety, which is causing their vitals signs to get worse.

This sounds both wrong and dangerous and dangerously wrong.

5) If you break a rib, the biggest concern is that rib might pierce the diaphragm.

This sounds both wrong and irrelevant.

6) fast and hard compressions are not a sign of good CPR.

If you mean "faster and harder is always better," I agree, but if you mean "slower and weaker is better," I definitely disagree. There is a correct rate and depth. It is fairly fast and hard, all things considered.

I might pass on the next class from those folks.

 

[DrParasite]

I might pass on the next class from those folks.

If it wasn't required by department policy (and required to maintain my EMT credential in this county) that I attend, I would skip every one of he classes. She has said so much questionable stuff, and some downright wrong stuff, that I've found the less I pay attention, the less incorrect information I retain. I can use my teaching to renew my NREMT, but because my county is "special," only con ed ran in county is acceptable to maintain yoour county credential.

The worst part is, it's not every instructor in the system, just her; I've attended classes elsewhere, and found the instructors to be substantially better (and one or two that was even worse). But for some reason department leadership loves her (for reasons I can't fathom), and uses her exclusively.

To be totally honest, I spent the entire class working on my presentation for the NC OEMS Expo. I think I got one mostly done, now I just need to work on the other.

Sorry for the tangent, but If you're a paramedic and what she told me doesn't raise any red flags with you, then I question your competency as a medic.

 

[jdemt]

I thought you were joking about the spicy food thing....not sure if that individual should be teaching.....As far as previous MI goes, A really smart guy once told me that pain is a poor predictor of illness. To me the most concerning thing about a rib fracture is desaturation (especially in multi systems trauma) secondary to lung damage or the pain of breathing itself, but I guess there’s a concern for diaphragm puncture too. I just figured she meant that capnography is a better indicator of good CPR.

 

[cprted]

Echoing @Brandon O 's comments, NTG, in the doses we give for suspected ACS does not have arterial dilating effects, only on the venous side. Giving sublingual NTG does not dilate coronary arteries. As well, the pain feeling like a patient's previous MI is one of the few history findings that does have positive predictive value to suggest ACS.

Interesting paper to read regarding the assessment of suspected ACS patients and the likelihood ratios associated with different physical and history findings.

https://ajp.paramedics.org/index.php/ajp/article/viewFile/523/589

 

[Alan L Serve]

Echoing @Brandon O 's comments, NTG, in the doses we give for suspected ACS does not have arterial dilating effects, only on the venous side. Giving sublingual NTG does not dilate coronary arteries. As well, the pain feeling like a patient's previous MI is one of the few history findings that does have positive predictive value to suggest ACS.

Interesting paper to read regarding the assessment of suspected ACS patients and the likelihood ratios associated with different physical and history findings.

https://ajp.paramedics.org/index.php/ajp/article/viewFile/523/589

SL NTG also improves collateral coronary circulation which really is the key to saving someone who is actively infarcting. In fact one might even suggest it's the most important mechanism when used in this way for this issue.

 

[E tank]

Been thinking a lot about NTG and RCA perfusion. RCA perfusion to a compromised RV (compromised for whatever reason) is a huge deal, we all know. A big deal is made regarding discerning inferior/inferio-septal/RV MI's before giving NTG and then to consider not giving it if the right side is suspected to be significantly involved.

The presence of an "adequate" systolic pressure aside, there are those systems that allow BLS personnel to assist the patient with taking their own NTG, with no EKG assessment at all. Presumably, these patients would have been "screened" for RCA dz and found appropriate candidates for the drug, though, but there'd be no guarantee that something wouldn't be cooking on the right.

So the question is, how rigorous are folks about determining RV involvement before NTG? No assessment is air tight so I'm also wondering if you've been burned by giving it and had problems. In the pre-hospital setting, does the concern as it is taught to you play out in day to day practice or is it more of an occasional zebra?