Chest Pain + Cardiac Emergencies

Module 5

Causes of Chest Pain

Cardiovascular

Respiratory

Gastrointestinal

Musculoskeletal
Psychological

Most Common Causes of Cardiovascular Chest Pain

Coronary Artery Disease (CAD)

Angina

Myocardio Infarction (MI)

Arrhythmias

Hypertensive Emergencies

Aortic Aneurysm/Aortic Dissection

Pericarditis

Cardiac Tamponade

Risk Factors of Coronary Artery Disease (CAD)

Old age

Male

Obesity

Family history

Smoking
Diabetes

Hypertension

Hyperlipidemia

Prolonged stress

sedentary lifestyle

Types of CAD

Stable angina pectoris

Unstable angina pectoris

myocardial infarction

Angina Pectoris

Angina Pectoris: Chest pain or discomfort due to ischemia

• Usually squeezing, tight, heavy, or contricting

• Also called ischemic chest pain

Separated into stable and unstable angina

Stable Angina (OPQRST: P)

• Worse with exertion, often ends by the time EMTs arrive at the scene

• Relieved by medications including nitro

Unstable Angina: Cause and Symptoms

Typically caused by a rupture of an atherosclerotic plaque (buildup of fats + cholesterol on the artery walls)

Symptoms:

• Occurs at rest rather than exertion

• Pain is severe and the onset is now (hasn’t happened before)

• Crescendo pattern (more and more pain each episode)

• Not received by rest or vasodilator medications

This can become a heart attack

Myocardial Infarction (MI)

A ruptured plaque blocking or occluding an artery leads to inadequate blood flow leading to inadequate oxygen (ischemia). This leads to death of heart muscle distal to the occlusion and is what we call a myocardial infarction

Difference between this and angina: This plaque doesn’t dissolve into the artery

Acute Coronary Syndrome

Myocardial Infarction and Angina (stable and unstable)

ST-Elevated Myocardial Infarction

• Type of MI that can be identified on a 12-lead EKG based on ST elevation

• Normal EKG has no elevation from the isoelectric line (ST line)

• STEMI EKG has substantial elevation on the isoelectric line

Patients without the STEMI EKG can still have a MI

Signs and Symptoms of Acute Coronary Syndrome (ACS): O

O: Gradual onset of pain (intensity can be constant or wax and wane without reason)

Signs and Symptoms of ACS: P

P: Provoked by activity, doesn't change with respiration or position

Signs and Symptoms of ACS: Q

Squeezing, tightness, pressure (they can also place clenched fist over their heart — called Levine’s sign)

Signs and Symptoms of ACS: R

R: Discomfort is often described as diffuse throughout the chest, radiates to upper abdomen, back, neck, arms, jaw, and teeth

Signs and Symptoms of ACS OPQRST: S

Severity varies (doesn’t indicate severity of ACS)

Signs and Symptoms of ACS: T

Duration is variable (generally >30 minutes) + is not resolved by rest or taking a vasodilator

Signs and Symptoms of ACS: Additional/Pertinent Negatives

Shortness of breath

Nausea/vomiting

Indigestion

Pale, cool, clammy skin

fatigue/weakness

Dizziness/lightheadedness

Any of these that the patient denies having are “pertinent negatives” and should be noted in the handoff

Atypical Presentations (Indicate it may not be ischemia)

Pleuritic (sharp pain that changes in intensity with breathing and coughing)

Can be localized with one finger

Can be reproduced with movement or palpation

Stars in mid/lower abdomen

Radiates to lower extremities or above the jaw

Lasts for days or is fleeting for a few seconds or less

These symptoms can also be indicative of other emergencies or other cardiac emergencies

ACS: Atypical presentation

• Don’t present with chest pain

Instead, they have:

• Fatigue or weakness

• Dyspnea

• Nausea/vomiting

• Palpitations

• Syncope

Be suspicious of ACS if a patient with history of heart disease or diabetes presents with these symptoms

More common in older people and in women

Hospital Destinations

Percutaneous Coronary Intervention (PCI): uses catheter with attached ballon to break up a clot + place a stent to open the occluded artery

Thrombolysis: Administration of a throbolytic drug that dissolves blood clots to open up the arteries

Coronary Artery Bypass Graft (CABG): Surgery to connect healthy vein or artery to a coronary artery to bypass a blockage

• Need to figure out what your patient’s issue is in order to determine where to sent the patient

Complications from an MI

Cardiogenic Shock

Heart Failure

Sudden Cardiac Death

Heart Failure

Occurs when cardiac output from the heart is insufficient to meet the needs of the body

• Can be caused by congestive heart failure (CHF), MI, or any other condition that overloads the heart

Heart Failure Explanation

Heart is damaged + its ability to pump decreases

• Heart attempts to compensate by speeding up and enlarging ventricles to increase cardiac output. When these compensatory mechanisms fail, heart failure occurs.

Right-Sided Heart Failure Symptoms + Effects

Leads to fluid backup in the systemic circulation

Symptoms:

• Jugular vein distension (JVD),

• Fluid accumulation in the abdomen

• Enlarged liver/spleen

Left-Sided Heart Failure

Leads to back up into pulmonary system

Symptoms:

• Pulmonary hypertension

• Pulmonary edema

• Congestive Heart Failure

Causes of Sudden Cardiac Death

Caused by MI and arrythmias

Most often caused by Ventricular Fibrillation (V-Fib)

Ventricular Fibrillation

Disorganized firing of electrical impulses in the ventricles

• Prevents formation of organized heart beats

• Leads to no cardiac output with no detectable pulse leading to cardiac arrest

Can be treated with an electrical shock (from the AED)

Arrhythmias

Abnormalities in the heartbeat from disruption to the heart’s electrical conduction system

Tachycardias are most likely to cause chest pain (140-240bpm)

Categories of Arrhythmias

Extra beats

Supraventricular Tachycardias

Ventricular Arrhythmias

Bradyarrhythmias

Arrhythmias: Extra Beats/Ectopic Beats

• Premature contraction of the heart occurring in the atria, junction, or ventricles

Not always noticeable in the patient’s radial pulse

Arrhythmias: Supraventricular Tachycardia

Rapid heart rate from the SA node, the atria, or the AV Node

Arrhythmias: Ventricular Arrhythmias

Ventricular Tachycardia (V-Tach):

Ventricular Fibrillation (V-Fib):Shockable rhythm for an AED

Arrhythmias: Bradyarrhythmias

Any arrhythmia with a slow heart rate

Valvular Heart Disease

Affects one or more of the four heart valves (aortic, mitral, tricuspid, pulmonary)

Affects more than 1 in 10 people 75+

Types of Valvular Heart Disease: Valvular Stenosis

Valvular Stenosis: The narrowing of the opening of a valve which restricts blood flow

Types of Valvular Heart Disease: Valvular Insufficiency

Valvular Insufficiency/valvular regurgitation: occurs when the valves don’t close sufficiently

Hypertensive Emergencies: Definition + Symptoms

Occur when systolic BP is over 180 mmHg or there is a rapid rise in BP

Symptoms:

• Headache

• Dizziness

• Nosebleed

• Changes in vision

• Ringing in ears

• Bounding pulse

• Chest pain

• Nausea + vomiting

Not all hypertension is a hypertensive emergency

Aortic Aneurysm

Ballooning of the aorta due to a weakened vessel wall (common in the abdomen)

Can be caused by uncontrolled hypertension

Symptoms of Aortic Aneurysm

Sudden, severe pain in the chest, back, abdomen, or flank

Can be asymptomatic until the aneurysm has expanded to affect other areas or if it is rupturing

Abdominal Aortic Aneurysm (AAA)

A pulsating mass in the midline of the abdomen (do not manipulate)

Symptoms of a Ruptured Aortic Aneurysm

Hypotension

Tachycardia

Progresses to unresponsiveness + cardiac arrest

Mass will no longer be visible

Aortic Dissection

Tear in the wall of the aorta allows blood to separate the layers in the wall of the aorta

Symptoms of an Aortic Dissection

Hypertension

Unequal blood pressure bilaterally

Hypotension: Indicates aortic rupture or cardiac tamponade

Abrupt tearing chest pain radiating to the back, front, or other parts of the torso

Effects of an Aortic Dissection

Hypertension

Unequal blood pressure bilaterally

Cardiac Tamponade

Accumulation of fluid in the pericardium contracts the heart and impedes filling. Then increasing pressure stops ventricles from filling adequately causing decreased output

Acute vs. Subacute Cardiac Tamponade

Acute: Onset of minutes to hours

Subacute: Onset between days to weeks

Symptoms of Cardiac Tamponade

• Sudden onset chest pain

• Tachycardia

• Tachypnea

• Beck’s Triad

Pulsus Paradoxus

Drop in systolic BP of greater than 10mmHg on inspiration

Beck’s Triad

Indicates Cardiac Tamponade

• Hypotension/narrowing pulse pressure

• JVD

• Muffled heart tones

Pericarditis

Inflammation of the pericardium (the sac surrounding the heart)

Signs/Symptoms of Pericarditis

• Sharp chest pain originating from under the sternum or on the left side of the chest

• Pain radiating to the lower part of the scapula on the back

• Pain is not changed by exertion

• Pain is worse while supine or on inspiration

• Sometimes have a fever

• Pain is sudden in onset + can last for hours or days

Respiratory Chest Pain Symptoms

Pain is often pleuritic and associated with shortness of breath

• sharp or stabbing

Causes of Respiratory Chest Pain

• Pulmonary Embolism

• Pneumothorax

• COPD

• Asthma

• Pneumonia/infection

Gastrointestinal Causes of Chest Pain

Foreign body obstruction

Gastroesophageal reflux disease (GERD)

Esophagitis

Esophageal rupture

Gallbladder Disease

Pancreatitis

Duodenal or peptic ulcer

Hepatic disease

Psychological Causes of Chest Pain

Stress + Anxiety

• Often have a history of similar episodes + have numbers/tingling in the extremities from

ACS should be a consideration even if it looks like anxiety

Musculoskeletal Causes of Chest Pain

• Contusion

• Rib Fracture

• Muscle strain or tear

• Costochondritis

Pain is often reproducible with movement or palpation

Signs and symptoms are localized to the area of the injury

Focued Exam for Chest Pain

Do the region above and below the pain

• Pay special attention to JVD and tracheal deviation

Chest:

• Expose chest to look for injuries, scars from previous surgery, mediation patches, implantable cardioverter-defibrillator (ICD/pacemaker)

• Check for equal and bilateral breath sounds

• Palpate where patient feels most pain

• Get all lung sounds

• Check distal pulses and look for edema in the extremities

• Check abdomen for tenderness, rigidity, and guarding (as well as pulsating mass for AAA)

Ventricular Assist Device

A pump that is surgically inserted in the left or right ventricle that partially or completely replaces the function of a failing heart

• Call the number with the person with the pump to be told best practices for how to treat a patient with this device

• Patients with a VAD might not have a pulse or blood pressure because the device is replacing the heart

History Questions for Chest Pain

Ischemic or non-ischemic pain?

Medications + Past Medical History of risk factors?

Smoking, drinking, and/or use of stimulants?

Family history of heart issues?