Chest pain

[Aidey]

The reason we all said anxiety is as follows.

1. She is 17.
2. She has no cardiac history.
3. She is 17.
4. She has normal vital signs.
5. She is 17.
6. She has no history of trauma.
7. She is 17.
8. She has no history of respiratory illness.
9. She is 17.
10. She is not at high risk for pulmonary embolism.
11. She is 17.
12. She has a normal EKG.
13. She is 17.
14. She has had this before without a diagnosis.
15. She is 17.
16. She is not at high risk for endocarditis/pericarditis/pleurisy.
17. She is 17.
18. There is no sign she has a pneumothorax.
19. She is 17.
20. There is no sign she has a pleural effusion.


I could keep going, but I think you get the point.

 

[EMT B]

why does anxiety initially present with cardiac symptoms? or is it different in everyone?

 

[Aidey]

I suggest you do some reading on anxiety and how it can present.

 

[EMT B]

will do. thanks for all your help guys!

 

[leoemt]

I doubt its anxiety. Not everything that isn't Cardiac is Anxiety. Yes Anxiety can cause heart palpatations and tachycardia. It also causes shortness of breath and headaches.

Any history of Anxiety attacks? History of Cardiac? Was she worried about something?

What was she doing the last time this occurred? How often does it occur?

I would consider a Caffeine reaction especially if she doesn't intake caffeine regularly.

Unlikely but also a consideration of Angina needs to be made - especially with the referred pain in the jaw.

Just because she is 17 is no reason to overlook a possible Cardiac problem. Many kids develop Cardiac problems especially with the poor diets and lack of exercise. Granted she is not obese but that does not rule out a cardiac issue.

It is possible for a cardiac problem to go unseen in the field as I found out recently. If this is chronic she should probably have a holter monitor for a day or two to see if it catches the problem.

 

[Aidey]

A caffeine reaction would present with a higher heart rate and blood pressure than she is exhibiting. Caffeine and other stimulants cause chest pain secondary to ischemia from either tachycardia and poor perfusion or vasoconstriction (or both).

You don't have to be worried about something to have an anxiety attack. They can be triggered by subconscious stimuli.

What is the rate of non-congenital cardiac events in 17 year olds with normal 12 leads?

Also, please define "many kids".

Angina is caused by oxygen deprivation to the heart muscle. What exactly do you propose is causing angina in this patient?

 

[JPINFV]

Not all that is cardiac is ACS, and 17 is a really good reason to push ACS far down the list.

 

[EMT B]

if its not ACS, and its not Anxiety, than what is it?

 

[NomadicMedic]

if its not ACS, and its not Anxiety, than what is it?

You posted the scenario... You tell us.

To me, it sounds like neuralgia... Comes and goes, is common, no docs have been able to find a cure, feels like an electric shock... I would transport her, but not treat her for ACS.

 

[EMT B]

after followup it turns out it is anxiety

 

[HMartinho]

if its not ACS, and its not Anxiety, than what is it?

hyperthyroidism. (or something metabolic)

This is just one example among many others.

 

[Anjel]

after followup it turns out it is anxiety

 

[mycrofft]

Don't give anxiety short shrift.
It is a symptom (hyperthyroidism, impending angina or MI, mental illness, social illness, polypharmacy legal and otherwise) as well as a fact of life for people such as teenagers. Extreme sadness has been empirically linked to sudden death among some groups ("so-called "broken heart syndrome").

 

[BigLouie2314]

The reason we all said anxiety is as follows.

1. She is 17.
2. She has no cardiac history.
3. She is 17.
4. She has normal vital signs.
5. She is 17.
6. She has no history of trauma.
7. She is 17.
8. She has no history of respiratory illness.
9. She is 17.
10. She is not at high risk for pulmonary embolism.
11. She is 17.
12. She has a normal EKG.
13. She is 17.
14. She has had this before without a diagnosis.
15. She is 17.
16. She is not at high risk for endocarditis/pericarditis/pleurisy.
17. She is 17.
18. There is no sign she has a pneumothorax.
19. She is 17.
20. There is no sign she has a pleural effusion.


I could keep going, but I think you get the point.

So apparently a 17yo can not have any legitimate acute medical problem. Have you considered pneumomediastinum? Drugs? Cocaine? Did anybody ask if the pt used any illegal drugs? Yes, she has no cardiac hx but how many young kids can have prolonged QT syndrome? More common thinsg could be URI, GERD, chest wall pain, myocarditis, precordial catch syndrome. Can't just think it's always "anxiety" because the pt has no documented hx or is 17 years old. No, it may not be a typical MI, but it absolutely could be a legitimate medical problem.

 

[Hunter]

So apparently a 17yo can not have any legitimate acute medical problem. Have you considered pneumomediastinum? Drugs? Cocaine? Did anybody ask if the pt used any illegal drugs? Yes, she has no cardiac hx but how many young kids can have prolonged QT syndrome? More common thinsg could be URI, GERD, chest wall pain, myocarditis, precordial catch syndrome. Can't just think it's always "anxiety" because the pt has no documented hx or is 17 years old. No, it may not be a typical MI, but it absolutely could be a legitimate medical problem.

No one said she couldn't however the index of suspicion for an acute mi on a 17 y/o is very low. But the cases of the examples you gave without any other history are very very unlikely. Besides it's happened before without diagnosis, which means it's probably happening again.

 

[Handsome Robb]

well yes i thought it was cardiac, however ALS did not, and I was wondering how you guys came up with Anxiety

Experience.

Most medics here wouldn't have even done an ALS workup. Once the monitor goes on it doesn't come off.

Not saying its right, but it happens all the time.

Probably would get kicked out by EMD as a priority 3 call.

 

[BigLouie2314]

Can't tell you how many providers (medics, nurses, even ED docs) have been burned tossing things up to anxiety without in-depth and proper assessments.

Yea, I used do it all the time, triage something back to BLS knowing its a BS chest pain, but one days that BS chest pain, is actually going to be one of those "less-likely" problems, which si what happened to me, which is why nobody, no matter age, hx, etc., just gets tossed up to "anxiety."

 

[Aidey]

So apparently a 17yo can not have any legitimate acute medical problem. Have you considered pneumomediastinum? Drugs? Cocaine? Did anybody ask if the pt used any illegal drugs? Yes, she has no cardiac hx but how many young kids can have prolonged QT syndrome? More common thinsg could be URI, GERD, chest wall pain, myocarditis, precordial catch syndrome. Can't just think it's always "anxiety" because the pt has no documented hx or is 17 years old. No, it may not be a typical MI, but it absolutely could be a legitimate medical problem.

Oh they definitely can, but she is not one of them.

Pneumomediastimum, GERD, chest wall pain/costochondritis, precordial catch syndrome etc are all great examples of conditions that don't normally require emergency treatment. Or any treatment outside of OTC meds.

Myocarditis is expected to have other signs/symptoms, including possible EKG changes. She has also been evaluated for this before without a diagnosis.

With the exception of cases of tracheal inflammation, a URI doesn't cause chest pain. And even with tracheal inflammation that is a stretch.

Long QT syndrome doesn't cause chest pain on its own. Palpitations from an arrhythmia could cause chest pain, but she had no signs of irregular beats or an arrhythmia.

So what if she has done illegal drugs? As I've mentioned before, she had no signs of a stimulant overdose. If she smoked pot and got chest pain, WTF is the ED going to do about it?

 

[NomadicMedic]

Do a through assessment, but it's usually horses, not zebras.

 

[Shishkabob]

So apparently a 17yo can not have any legitimate acute medical problem.... No, it may not be a typical MI, but it absolutely could be a legitimate medical problem.

Sure it can, but just because it "can" be something doesn't mean I'll treat it as such. After doing my assessment, we go off of my diagnosis. I, like most medics here, don't go all willy-nilly with things to do without actually thinking about a cost/benefit for the given situation.