Chest Pain Diagnosis

[High Speed Chaser]

Hey all,

We have been learning about Acute Coronary Syndrome and treatment and I'm not 100% clear on how to differentiate the typical signs and symptoms of ACS VS Pleuritic VS Muscular pain.

While I understand that the symptoms can not always signify a certain route of diagnosis and that each person can vary significantly in presentation of chest pain, I'm just trying to gain an understanding of common signs, symptoms and events leading to onset that can be used to identify red flags and help form a clinical picture of what is actually going on so it can accurately treat it.

I'm not looking for ECG findings to help form the picture (hence why I thought it would be best to post in BLS and not anywhere else,) nor treatment, just looking to understand how and why to diagnose chest pain in a pre-hospital environment.

Cheers

 

[Katy]

Typically, ACS will present itself with chest pain, as you described, but that is far to vague to make a real diagnosis on. It does, however, commonly present itself with other symptoms and signs that may help you distinguish it;
- diaphoresis
- often, the pain is described as "tightness"
- pain running toward the left side (arm)
- pain is usually something odd and the patient can tell it is not a common muscle tightness
These are some of the other symptoms that can occur when ACS is present, but I cannot think of a way that one would have a certain diagnosis in the field without a proper ECG. Health history can also be a big part of catching any type of cardiac issue most of the time. Good luck in your studies.

 

[Wes]

Just to clarify, ACS/myocardial infarction doesn't always present with chest pain. It's sometimes a bugger to identify. I have seen severe cases even present with nothing more than nausea.

A medical director I once practiced under gave the following advice regarding ACS. 25% of patients present typically, 25% present with no symptoms, and 50% present atypically.

I don't know if those statistics are accurate, but they make a heck of a teaching tool.

 

[EMS Patient Care Advocate]

Hey all,

We have been learning about Acute Coronary Syndrome and treatment and I'm not 100% clear on how to differentiate the typical signs and symptoms of ACS VS Pleuritic VS Muscular pain.

While I understand that the symptoms can not always signify a certain route of diagnosis and that each person can vary significantly in presentation of chest pain, I'm just trying to gain an understanding of common signs, symptoms and events leading to onset that can be used to identify red flags and help form a clinical picture of what is actually going on so it can accurately treat it.

I'm not looking for ECG findings to help form the picture (hence why I thought it would be best to post in BLS and not anywhere else,) nor treatment, just looking to understand how and why to diagnose chest pain in a pre-hospital environment.

Cheers

Well they would have a history suggestive of pleuritic disease/illness and muscular pain. Muscular pain and pleuritic pain also tend to be reporducable pain, where ACS is pain that may not be relieved. I constantly remind paramedics and patients that a small percent of heart attacks are STEMI identifiable by ekg only. Assessment and OPQRS line of questions should give you a more narrow direction when trying to pic one of the three. Hx is huge. Did he have truama to the chest prior to the chest pain- chest pain doesnt HAVE to be cardiac as you stated.

 

[systemet]

* You need serial 12-lead and troponins to rule out MI. Can't rule out based on a single ECG.

* Diagnostic sensitivity of the 12-lead for MI is only ~40% in most leads, i.e. ~60% of patients infarcting will lack ST changes. The absence of ECG changes isn't that meaningful.

* While uncommon, ischemic pain can be reproducible upon palpation.

* Symptom severity doesn't always correlate with the severity of the disease, e.g. diaphoretic, vomiting, messes sometimes end up being UA. Dizzy old ladies are sometimes full blown STEMIs.

* NTG can relieve pain of non-cardiac origin.

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Edit: Just realised you wrote "not looking for ECG findings....". Oh well, I'm going to leave it up anyway. Short of a very clear history and signs of recent trauma, and the absence of cardiac history, in a patient with minimal risk factors, it's very difficult to rule-out a cardiac etiology.

 

[Katy]

* Symptom severity doesn't always correlate with the severity of the disease, e.g. diaphoretic, vomiting, messes sometimes end up being UA. Dizzy old ladies are sometimes full blown STEMIs.

This is a very very good point to keep in mind.

 

[Katy]

Pluerisy vs ACS

You also brought up how to differ plueritic pain and ACS pain. Well, pluerisy pain is usually caused by an infection, such as Pneumonia. Second, it is when inflammation of the lining of the plueral cavity, or pluera occurs, thus causing friction when the patient breathes.. This pain is increased with inhalation and coughing most often, and is described as a very sharp pain that eases some with less respiratory activity. ACS pain, when it presents itself and you rule out other possible causes, usually can be pointed out because of it's "constant" patterns.

 

[the_negro_puppy]

I think some of the biggest things too look for can be found in the patients history-

- Do they have a cardiac hx? how about risk factors such as HTN, Diabetes, high cholesterol, overweight, smoking etc. DO they have a family hx of cardiac problems?

- How long has the pain been there? what were they doing when it started? A person that calls 000 for chest pain thats been ongoing for 2 weeks is unlikely to be suffering from AMI. Whereas a pt who was at rest and had onset of chest pain or other symptoms and call an ambulance in a reasonable with the pain 'new' should ring some more bells.

- As other have said there doesn't have to be typical crushing chest pain for AMI. I've had many patients who have had M.Is and stated they had dizziness, syncope, weakness, SOB without pain symptoms. Pain can also be in the back or arm, or even a mild tingling in the jaw.

- Being able to re-produce the pain or relieve it through position doesn't necessarily rule out AMI either.

Even if you obtain a 12 lead with N.A.D, if the pt is still suffering pain symptoms and you have an index of suspicion it could be ischaemic chest pain, if in doubt treat it as iscahemic chest pain. We can not rule out ischaemia pre-hospital, and aspirin, 02, small amounts of GTN and morphine hopefully will do no harm if they pt is not infarcting, whereas mis diagnosing an ischaemic event and not treating as such will.

 

[MonkeySquasher]

Just to clarify, ACS/myocardial infarction doesn't always present with chest pain. It's sometimes a bugger to identify. I have seen severe cases even present with nothing more than nausea.

* You need serial 12-lead and troponins to rule out MI. Can't rule out based on a single ECG.

Symptom severity doesn't always correlate with the severity of the disease, e.g. diaphoretic, vomiting, messes sometimes end up being UA. Dizzy old ladies are sometimes full blown STEMIs.

^ These. If they're older, if they're bigger, if they have diabeties, if they're female, if they have cardiac history, if they're on an analgesic for other pain.. These are all things that can cause masking of a cardiac event.

Basically, if they're over 40 and something's wrong, I leave "cardiac" under DDx until proven otherwise. Things like nausea, acute onset SOB with no clear cause/history, sudden or recent onset weakness, sudden hypo- or hypertension.. ESPECIALLY syncope... All rule-in an AMI, in my opinion.

 

[Akulahawk]

Cardiac chest pain normally isn't point-tender. It may be difficult for the patient to indicate exactly where the pain or discomfort is. Musculoskeletal pain is typically point-tender or at least is very specific about location and it won't normally radiate.

MI can (as stated already) be quite the bugger to diagnose, so... unless I'm absolutely convinced it's not an MI... it's going to be on my list of worries.

And given that the more I'm certain about something the more likely nature has decided to teach me that I'm wrong... I'm never that certain.