Chest Pain

[truetiger]

Nothing hard here...just figured I'd add a fresh scenario.

You are dispatched for "cardiac complications." You are told your patient is an 80 something year old female complaining of chest pain and hypertension. You arrive on scene to find your patient seated in a rocking chair. She stated she has having substernal chest pressure and rates it an 8/10. Nothing relieves or provokes the pain. It does not radiate. She stated this began this morning (time of call was 0730) and that she took her blood pressure (automated device) and found it to be 215/93. She stated she was hospitalized 3 days ago for the same problem and the outcome of that was an adjustment to her HTN meds.

General impression of this patient is of no distress. ABC's good. She complains of minor SOB and has a regular radial pulse (70's). Patient is loaded onto the stretcher and taken to the rig. EKG, pulse ox, 12 lead applied/performed. Sinus rhythm, 96% on RA, and a non diagnostic 12 lead. Patient no longer complaining of any chest pain.

Your choices of hospital are a regional medical center with a cath lab that is 25 mins away or the local hospital that is 10 mins away.

What would you do for this patient?

 

[Handsome Robb]

Hmm. Lung sounds? Work of breathing? What was the BP when you took it? What meds does she take for her HTN specifically? Any other medical conditions besides her HTN? Hx of MI's, CABGs, Angina? Recent surgeries? What did they change in her meds? Was she admitted to the hospital 3 days ago or just an ER/GP visit? If admitted how long did she stay? Did they have a dx or just change her meds? Is she Rx'd NTG? If so has she taken any with any relief also when was the Rx filled, how/where is it stored? Did the pain wake her up or did she wake up and then begin experiencing her pain when she got herself up and mobile? Abd pain? Indigestion? Depending on whether she was woken by the pain or if it started after she was up and about I'm leaning towards angina personally, however it hasn't resolved itself...

I vote local ED. No proof saying she needs a cath lab at the moment. With no ST changes in the 12 lead I'm leaning towards not needing a cath lab right this second. Local ED can do labs looking for cardiac enzymes and determine if she needs to be transfered out. Just my 0.02 but like many instructors have told me when you hear hoofbeats look for horses not zebras. I feel like that's someone's signature on here too.

 

[truetiger]

Lung sounds clear. Breathing was 20/unlabored. Manual BP was 144/100. She wasn't specific as to what meds she was taking for HTN, only that they adjusted the dose. No HTN meds found in her "bag." Sounds like an ER visit. Problem has been going on x2 weeks. Multiple ER visits over this time period. She has prior hx of MI, stents x3. Nitro was prescribed and not taken. She stated the pain has been constant x2 weeks but felt worse today. Pain did not wake her. She was seated in a rocking chair upon our arrival. Upon being placed onto the cot and semi fowlers the pain went from an 8 to 0.

 

[mycrofft]

Well, moving her from her chair to the litter may have alleviated the pain.

By "nothing relieves or provokes" I assume this is by hx, you didn't push on her sternum or have her take a deep breath or stand up, swallow, etc.
BP: if abnormal, get a manual one to confirm. Watch out for drug interactions if you treat, and make sure her med hx is as correct as you can get it.
Local ER, r/o eosophagus r/o, costo-chondritis, r/o thoracic vertebral impingement, r/o hiatal hernia etc.

 

[truetiger]

Pain was not reproducible with palpation. Patient stated she had been ambulatory prior to our arrival, which had no affect on her pain.

 

[Handsome Robb]

Did it feel like her prior MIs? Any 'impending doom'? Dietary changes? Compliant with her meds? Why didn't she take the nitro?

144/100 is high but not unheard of with a hx of HTN. I'm still sticking with my ddx of angina and the local ER.

 

[truetiger]

No impending doom. Stated it felt like her last and only MI. Pain has been present x2 weeks, multiple ER visits with no diagnosis. Says she's compliant, mind you her attitude during this whole episode gives you a sneaking suspicion that she is not. No idea on the nitro to be honest.

 

[Sodapop]

Wondering which hospital she was at for the recent stay? Local or the Cath lab facility. Assuming the previous MI's and Stents were placed at the facility 25 minutes away I would lean towards transporting there so that 12 leads can be compared to past for a comparison.

Probably follow chest pain procotols (MONA) IV, give ASA, Nitro and O2 via N/C. Continue to monitor during transport. Granted the current EKG's do not appear alarming but I would error on the side of going to the facility that has her previous records from the stents and such for comparison. Hopefully the vessel dilation from the Nitro will relieve the pain and help bring the pressure down. O2 Sat is not terrible so a little O2 will hopefully bring it up.

 

[truetiger]

Patient was seen at the local non cath lab ER. The patient was pain free by the time we got out to the rig, so no nitro.

 

[crazycajun]

I would have to hit the Cath Lab. PT has had 3 stents + MI for Hx. Although I have never seen it I have heard of a stent moving causing angina and certain positions relieving pain.

 

[DV_EMT]

I'd go to cath lab. If the Pain has been present for that long and she has a Hx of cardiac complications, Cath Lab may be the best route... worse comes to worse they admit her and shove her on a telemetry unit for cardiac monitoring to troubleshoot that cause of pain

 

[mycrofft]

I like soda pop's reply. However...

In the absence of an abnormal manual BP (the BP you cite is her version of her amateur automated machine's reading) or even professional machine BP, and in the presence of normal EKG and pulse,we are looking at either a variable pain, or a variable report of pain.
So, what can cause these?
But, as field practitioners, the essence is still gather reasonable data and go.

 

[truetiger]

BP was 144/100 manual, as taken by my partner.

 

[mycrofft]

OK, variable pain or a variable report/hx.

Coronary spasm=> anginal attack? Psychological? Psychosomatic (broken heart syndrome)? Psychosocial (lonely)? Need to r/o physical first and get some labs anyway.