chapter 28 chest pain. © 2005 by thomson delmar learning,a part of the thomson corporation. all...

Chapter 28Chest Pain

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved

2

Overview

Anatomy and Physiology Review Coronary Artery Disease

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Anatomy and Physiology Review

The left heart– Left ventricle pumps blood around the systemic

circuit• Includes entire circulatory system outside lungs

– Blood pressure estimates function of left ventricle– Systolic pressure: pressure in arteries during

contraction of the heart• Will be low if left ventricle is not pumping adequately

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Anatomy and Physiology Review

The left heart– Diastolic pressure: pressure in the circulatory

system during relaxation phase of the heart– Increased resistance to blood ejected by left

ventricle can result in higher blood pressure or hypertension

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Anatomy and Physiology Review

The right heart– Has a relatively easier job than the left– Pumps exclusively to the lungs

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Anatomy and Physiology Review

The right heart– Pumps the same amount of blood as the left – Relatively low resistance in the pulmonary

circuit allows easy circulation of blood throughout the lungs

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Anatomy and Physiology Review

Coronary circulation– Heart’s circulation derives from the first two

arteries that arise from the base of the aorta– These coronary arteries supply the heart with

oxygenated blood

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Coronary Artery Disease

Cardiovascular disease is the number one killer of Americans over the age of 35

A large segment of the U.S. population is over 35, making CAD a significant health concern

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Coronary Artery Disease

Pathophysiology: Development– Blood circulates oxygen and nutrients, including

lipids, throughout body – Fatty streaks: fat deposits on blood vessel walls – Atherosclerosis: buildup of fatty streaks over time

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Coronary Artery Disease

Pathophysiology: Development– Plaques or atheromas

• Accumulated fat deposits in bends restricts blood flow• Plaque narrows and blocks blood vessels

– Thrombus: blood clot in narrowed vessel– Tissue becomes deprived of oxygen-rich blood

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Coronary Artery Disease

Pathophysiology: Angina– Insufficient amount of oxygenated blood for

patient’s needs causes chest pain or other symptoms

– Narrowed coronary arteries cause the myocardium to receive less oxygenated blood

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Coronary Artery Disease

Pathophysiology: Unstable angina– Further narrowing of coronary arteries causes

angina even upon patient’s less exertion or when patient is at rest

– Indicates a more serious disease

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Coronary Artery Disease

Pathophysiology: Acute myocardial infarction (AMI)– Very narrow coronary arteries prevent

oxygenated blood from reaching the myocardium • Myocardial cells begin to die

– Interferes with body’s ability to effectively pump blood

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Coronary Artery Disease

Pathophysiology: Acute myocardial infarction (AMI)– Injured tissue around infection site

becomes irritable • Inadequate pumping action • Cardiogenic shock or erratic heartbeat • Sudden cardiac death can result

– Acute coronary syndrome (ACS): continuum of conditions affecting blood flow to the heart

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Coronary Artery Disease

Risk factors: Modifiable– Voluntary behaviors

• Smoking and drug use• Lack of exercise• Diet high in cholesterol• Diet that leads to obesity

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Coronary Artery Disease

Risk factors: Nonmodifiable– Innate factors

• Gender • Heredity• Diabetes• Hypertension

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Stop and Review

What are some modifiable risk factors for AMI?

What is the disease process that causes coronary artery disease?

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Coronary Artery Disease

Signs and symptoms– Tachycardia

• Very fast heart rate of over 100 bpm• Profound tachycardia can cause hypotension

– Bradycardia• Very slow heart rate of under 60 bpm• Severe bradycardia can cause hypotension

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Coronary Artery Disease

Signs and symptoms– Diaphoresis Cool clammy skin– Other

• General weakness and nausea• Appears very ill and pale

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Coronary Artery Disease

Signs and symptoms: Chest pain– Broad, sweeping complaints

• “Dull ache”• “Stabbing”• “Crushing”• “Like an elephant sitting on my chest”

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Coronary Artery Disease

Signs and symptoms: Chest pain– Every patient may describe pain differently– Common complaints among males

• Lower jaw pain or neck pain• Indigestion or shortness of breath• Left shoulder or arm pain

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Coronary Artery Disease

Noncardiac chest pain– Chest pain may be due to disorders other

than an AMI – Stomach disorders can create similar pain

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Coronary Artery Disease

Assessment– Consider all complaints of chest pain as cardiac in origin

unless proven otherwise– Failure to assess and treat all chest pain as a potential

cardiac event may result in an unfortunate outcome for the patient

– Err on the side of safety

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Coronary Artery Disease

Initial assessment– Scene safety– Form general impression– Assess and manage ABCs

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Coronary Artery Disease

Unresponsive cardiac patient– Assess ABCs – If no breathing or circulation, start CPR

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Coronary Artery Disease

Responsive cardiac patient– After initial assessment, proceed to a history of the

present illness and a focused physical exam

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Coronary Artery Disease

Focused history: SAMPLE and OPQRST– “What were you doing when you first noticed the

discomfort?”– More than half of heart attacks occur while the

patient was resting or sleeping– Some occur as a result of some type of stressor

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Coronary Artery Disease

Focused history: Provocation– “What makes the discomfort better or worse?”– “Does it hurt to take a deep breath?”– Does the pain subside when the patient is sitting up

or lying down?– Did patient take any medications? Antacids for

indigestion?

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Coronary Artery Disease

Focused history: Quality– Ask patient to describe the pain in his own words– Ask open-ended questions– Avoid putting words into the patient’s mouth

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Coronary Artery Disease

Focused history: Radiation and severity– Does patient have neck or jaw pain?– Does pain radiate into the left shoulder or arm?

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Coronary Artery Disease

Focused history: Radiation and severity– Ask the patient to gauge the pain on a scale of

0 to 10– No amount of discomfort should be dismissed

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Coronary Artery Disease

Focused history: Time of onset– Denial of chest pain often results in a significant

loss of time before medical assistance is sought– A significant number of heart attack victims will die

within the first 2 hours from onset of chest pain

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Coronary Artery Disease

Focused history: Time of onset– Some therapies in the hospital depend upon how

long the symptoms have been present

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Time is crucial. Many AMI patients die within the first 2 hours from the onset of chest pain.

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Coronary Artery Disease

Focused physical examination– Physical changes demonstrated by patient result

from hypoperfusion to the heart and the body’s efforts to compensate using adrenaline (epinephrine)

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Coronary Artery Disease

Focused physical examination – Look for

• Dilated or sluggish pupils• Jugular venous distension (JVD)• Pulmonary edema

– Listen for• Wheezes• Crackles

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Coronary Artery Disease

Baseline vital signs– Get an accurate baseline set of vital signs– Baseline helps determine the speed at which the

patient’s condition is changing– If pulse oximetry is available, obtain a reading at

this time

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Coronary Artery Disease

Management– Place patient in a position of comfort– Place standing patient in seated or lying position– Bring stretcher to patient to prevent further

exertion

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Coronary Artery Disease

Management – Loosen restrictive clothing– Provide reassurance– Provide high-flow oxygen by non-rebreather mask

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Coronary Artery Disease

Nitroglycerin– Administer patient’s nitroglycerin according to local

protocols if • Patient has been prescribed • EMT is trained to administer

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Coronary Artery Disease

Nitroglycerin– Double-check that the nitroglycerin prescription

belongs to the patient– Measure blood pressure before and after

administration

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Nitroglycerin, a potent vasodilator, is used to relieve some of the work of the heart.

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Coronary Artery Disease

Transport– Don’t allow patient to walk to the ambulance or even to

the stretcher– Ensure patient is in a comfortable position– Transport patient quickly, without lights and sirens, to the

hospital to avoid increasing stress to the patient

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Coronary Artery Disease

Aeromedical transportation– Time is muscle – Ground-based EMS unit may be tied up in

traffic or vast distances may cause delay – Consider air medical services

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Coronary Artery Disease

ALS intercept– Advanced life support personnel can perform

many traditional ED functions while in the field

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Coronary Artery Disease

Ongoing assessment– Repeat vital signs often

• A set before and another after administration of nitroglycerin are needed

– Did pain lessen after oxygen was given?– Did the nitroglycerin help relieve the pain?

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Coronary Artery Disease

Fibrinolytics– A class of drugs formerly called thrombolytics– Can help open blocked arteries– Most effective within first few hours after

onset of symptoms– Important that EMT quickly transport the

AMI patient

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50

Coronary Artery Disease

Interventional cardiology– A more direct way to open a blocked vessel is to

mechanically remove the blockage• Angioplasty

– Only certain hospitals designated as heart centers have the capabilities to perform interventional cardiac procedures

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51

Stop and Review

List two major signs and symptoms of cardiac-related disorders.

What are the main prehospital treatments for chest pain?