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.
