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Sorting It Out: Chest Pain, Cardiac Arrest and SOB

Sorting It Out: Chest Pain, Cardiac Arrest and SOB. Michael Lohmeier, MD June 24, 2014. Sorting It All Out…. Before I begin… Thank You for this opportunity A Little About Me… Michael Lohmeier Assistant Professor of Medicine, Emergency Med

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Sorting It Out: Chest Pain, Cardiac Arrest and SOB

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  1. Sorting It Out: Chest Pain, Cardiac Arrest and SOB Michael Lohmeier, MD June 24, 2014

  2. Sorting It All Out… • Before I begin… • Thank You for this opportunity • A Little About Me… • Michael Lohmeier • Assistant Professor of Medicine, Emergency Med • Medical Director; Madison Fire, FitchRona EMS, Middleton EMS, Dane County EMS, UW PD First Responders • Medical Director, University of Wisconsin EEC • Director, EMS Rotation for Residents

  3. Sorting It All Out… • Per the Wisconsin EMS Association Website • 598,416 calls for EMS in 2011 • 15% increase from 2010 • 40% of calls are responded to by 10 services in the state • In 1992, only 9% of Wisconsin ambulance services operated at the Paramedic level • Today, 32% of services are licensed at this level • 68% of services are trained and authorized to start IVs and administer 8 or more medications • ~20% of calls require the administration of one or more meds • ~10% are true “life threatening” situations • That’s 59,000 patients per year! https://www.wisconsinems.com/ems-for-the-general-public/wisconsin-ems-statistics/

  4. Sorting It All Out… • Quotable • “The only man who never makes a mistake is the man who never does anything.” -Theodore Roosevelt

  5. Sorting It All Out… • Why should you care? • Chest Pain is one of the most common reasons for activating 9-1-1 • Unofficial Dane County Data • Emergency Department data • Not everything that presents with chest pain is cardiac • Time lost is muscle lost • EMS is triaged to cardiac cath labs in many parts of the state • The public expects you to get it right • Misdiagnosing an MI can be deadly! • Aortic dissection • Pericarditis http://www.cdc.gov/nchs/fastats/emergency-department.htm http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2010_ed_web_tables.pdf

  6. Sorting It All Out… • Chest Pain, Shortness of Breath and Cardiac Arrest can be on a spectrum of cardiac ischemia – or completely unrelated! • Approximately 129.8 million people visit the ED in 2010 • 5.4% of visits for chest pain • 2.7% of visits for shortness of breath • 2.7% of visits for cough • Critical diagnoses causing either varies widely • ACS, aortic dissection, pulmonary embolism, tension pneumothorax, pericardial tamponade, esophageal rupture http://www.cdc.gov/nchs/fastats/emergency-department.htm

  7. Sorting It All Out… • Differentials • Chest Pain • Acute MI • Unstable Angina • PE • Aortic Dissection • Pneumothorax • Cardiac Tamponade • Esophageal Rupture • Pericarditis • Shortness of Breath • Asthma and COPD • Pneumonia • Pneumothorax • Pulmonary Embolism • Trauma • Acute Coronary Syndrome • Endocrine (DKA, metabolic acidosis) • Hematologic (anemia) • Toxins (Salicylate overdose) • Ascites

  8. Sorting It All Out… • Differentials • Chest Pain • Acute MI • Unstable Angina • PE • Aortic Dissection • Pneumothorax • Cardiac Tamponade • Esophageal Rupture • Pericarditis • Shortness of Breath • Asthma and COPD • Pneumonia • Pneumothorax • Pulmonary Embolism • Trauma • Acute Coronary Syndrome • Endocrine (DKA, metabolic acidosis) • Hematologic (anemia) • Toxins (Salicylate overdose) • Ascites

  9. Sorting It All Out… • What causes chest pain? • Afferentnerve fibers carry signals from the body to the brain • Fibers from the heart, lungs, great vessels and esophagus enter the same thoracic dorsal ganglia • These ganglia overlap the 3 segments above and below • Location and quality of the pain are indistinct to the patient • Can be from the jaw to the epigastrium • Some somatic afferent fibers synapse in the same dorsal root ganglia and can “confuse” the CNS • Gives referred pain

  10. Sorting It All Out… • What causes shortness of breath? • “dyspnea” is the term used for the sensation of breathlessness and the patient’s reaction • Neither the clinical severity nor the patient’s perception correlates well with the seriousness of underlying pathology • The actual mechanisms for dyspnea are unknown • Imbalance between the respiratory center in the medulla oblongata and the chemoreceptors near the carotid bodies • Increased work of breathing • Increased respiratory drive

  11. Sorting It All Out… • Just to recap… • Chest Pain is indistinct to the patient, source may be unclear on exam • Dyspnea is subjective, may be related to a physical, metabolic or psychiatric condition • Differential is enormous, from non-emergent to the most critical diagnoses in medicine • Awesome. http://healthinessbox.files.wordpress.com/2012/09/chest_pain.jpg

  12. Sorting It All Out… • What are the life threats, and does this patient need an intervention immediately? • There is no simple algorithm • Keep your approach organized and systematic • Keys to narrow down your differential will be in the history, physical exam and EKG in ~90% of patients • Majority of diagnosis is going to come from the history • If they’re already in cardiac arrest, run the ACLS algorithms • Designed to treat the underlying etiologiy of arrest • We want to prevent that from happening!

  13. Sorting It All Out… • History • Don’t forget your O-P-Q-R-S-T! • Onset • What were you doing when you started having pain? • Provocation or palliation • What makes the pain better or worse? • Quality • Can you describe the pain? Sharp, dull, achy, stabbing, burning? • Region and Radiation • Where is the pain, and does it go anywhere? • Severity • On a scale of 0-10 with zero being no pain, how bad does this hurt? • Timing • How long has this been going on and how has it changed since the beginning? http://www.emtresource.com/resources/acronyms/opqrst/

  14. Sorting It All Out… • History • A history of prior pain and the diagnosis can be quite helpful in narrowing down your differential • But beware – the biggest barrier to making the correct diagnosis is… • The previous diagnosis!! • Associated symptoms may be helpful as well • Diaphoresis should suggest a serious or visceral cause • Hemoptysis is a classic PE sign – that is seen in about 1/5 the time • Nausea and Vomiting can be GI or cardiac in nature • Risk factors are important to consider when evaluating a patient • Good to know from a population basis, not as helpful with the individual

  15. Sorting It All Out… • Helpful Physical Exam findings • Appearance • Acute Respiratory Distress • Diaphoresis • Vital Signs • Hypotension • Tachycardia • Bradycardia • Hypertension • Fever • Hypoxemia

  16. Sorting It All Out… • Helpful Physical Exam findings • Cardiovascular Exam • Asymmetric Upper Extremity Blood Pressures • Narrow Pulse Pressure • New Murmur • S3/S4 Gallop • Pericardial Rub • Audible Systolic “Crunch” (Hamman’s Sign) • JVD • Pulmonary Exam • Unilateral Diminished Breath Sounds • Pleural Rub • Subcutaneous Emphysema • Rales

  17. Sorting It All Out… • Helpful Physical Exam findings • Abdominal Exam • EpigastricTenderness • LUQ Tenderness • RUQ Tenderness • Neurologic Exam • Focal Findings • Stroke

  18. Sorting It All Out… • Field Evaluation • EKG • Should be performed within 10 minutes of patient contact • All male patients >33 years old and all female patients >39 years old with a pain complaint between the jaw and the belly button • Time lost is muscle lost! • New Injury Pattern • Right Heart Strain • Diffuse ST segment elevation

  19. Sorting It All Out… • Prehospital Emergency Care • March 19, 2013 • “Field Activation of the Cath Lab Improves Door-to-Balloon Time” • Small, prospective observational study • Paramedics trained to interpret 12-leads were permitted to bypass the ED and transport directly to the cath lab • 38 prehospitalactivations, 47 activations after arrival and 28 walk-ins • 90 minute door-to-balloon benchmark was met 100% of the time when activated ahead of time • 72% for activation after arrival • 68% for walk-ins

  20. Sorting It All Out… • What are the “can’t miss” causes of chest pain and SOB I need to worry about? • Myocardial Infarction • Unstable Angina • Aortic Dissection • Pulmonary Embolism • Pneumothorax • Esophageal Rupture • Pericarditis

  21. Sorting It All Out… • What are the “can’t miss” causes of chest pain and SOB I need to worry about? • Myocardial Infarction

  22. Sorting It All Out… • What are the “can’t miss” causes of chest pain and SOB I need to worry about? • Unstable Angina

  23. Sorting It All Out… • What are the “can’t miss” causes of chest pain and SOB I need to worry about? • Aortic Dissection

  24. Sorting It All Out… • What are the “can’t miss” causes of chest pain and SOB I need to worry about? • Pulmonary Embolism

  25. Sorting It All Out… • What are the “can’t miss” causes of chest pain and SOB I need to worry about? • Pneumothorax

  26. Sorting It All Out… • What are the “can’t miss” causes of chest pain and SOB I need to worry about? • Esophageal Rupture

  27. Sorting It All Out… • What are the “can’t miss” causes of chest pain and SOB I need to worry about? • Pericarditis

  28. Sorting It All Out… • Summary • Chest Pain and Shortness of Breath • Very common reasons to seek medical treatment • NOT very easy to sort out • Etiology from the benign to the immediately life threatening • The burden is on us the medical providers to figure out what’s happening with the patients • Most of the answer comes through the history and 12-lead • If you don’t act on the information you get, the patient can arrest!

  29. Sorting It All Out…

  30. Sorting It All Out… • Quotable • “I never did a day’s work in my life. It was all fun.” -Thomas Edison

  31. Sorting It All Out… • Thank You!

  32. References • CONE DC, Lee CH, Van Gelder C 
EMS activation of the cardiac catheterization laboratory is associated with process improvements in the care of myocardial infarction patients.PrehospEmerg Care. 2013;17:293-8. • http://jama.jamanetwork.com/article.aspx?articleid=1568253 • http://ecg.utah.edu/lesson/9 • http://www.nursingconsult.com/nursing/patient-education/image?DOCID=10087&PAGE=en_%7B5184704e-d597-4edd-b169-dd09df788588%7D.jpg&module=patEdu • http://en.wikipedia.org/wiki/Aortic_dissection • http://www.nhlbi.nih.gov/health/health-topics/images/pericarditis.jpg • http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2010_ed_web_tables.pdf • http://afghanheart.files.wordpress.com/2013/02/my-cards-pneumothorax.jpg • http://emstopics.com/ChestPainReadingMain.htm • http://www.cdemcurriculum.org/ssm/cardiovascular/cv_acs.php

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