Chest Pain (ALS)

History Of Present Illness

Rescue 86 is called to a private residence for “chest pain.” The crew arrives to see a 58-year-old man
sitting on a couch in the living room. The patient is complaining of sudden sharp left anterior chest pain
that is worse with inspiration and accompanied by mild shortness of breath. No radiation, no sweating,
no exertional symptoms, and no history of similar symptoms in the past. He has no other complaints. No
recent cough or fever. No recent illness. No trauma.

Past medical history :  None

Medications:  None

Allergies:  None

Social history:  Smokes 1 pack per day, no alcohol, no illicit drugs

Last meal:  2 hours ago

Vital  signs :

 Temp  98.6°F (37.0°C)
 BP  140/90
 Resp  18
 Pulse  120 (regular)
 O 2 sat  93% on room air; 96% on oxygen

Blood sugar: 120 mg/dL (6.7 mmol/L)

Physical Exam

General:  Alert, no distress, head is atraumatic.

HEENT:  Pupils are equal and reactive to light, extraocular motions intact, no JVD, no evidence of head
trauma.
Neck:  No midline tenderness. 
Lungs:  Clear bilaterally.
Cardiac:  Regular rate and rhythm, no pain with palpation, no bruising to chest wall.
Abdomen:  Soft, non-tender, no masses, no rebound, no guarding, no bruises or signs of trauma.
Back:  No evidence of trauma, non-tender.
Extremities:  No evidence of trauma, non-tender, no peripheral edema. 
Skin:  Pale, diaphoretic, no wounds.
Neuro:   Alert and oriented x3, no motor deficits, nonfocal exam, no facial asymmetry, speech is clear,
stroke screen is negative, GCS is 15.
Assessment Of This Case

Chest pain is a very common symptom of patients presenting to both EMS agencies and Emergency
Departments. Of all Emergency Department patients, 5% present with the complaint of chest pain. The
challenge with the patient complaining of chest pain is to use your history and physical exam skills to
narrow down the possibilities. 

The causes of chest pain can range from very benign (i.e. musculoskeletal pain) to serious (i.e.
myocardial infarction, pulmonary embolism, pneumothorax, aortic dissection). 

Be aware of abnormal heart rhythms. Be prepared for bradycardia, heart blocks, and ventricular
fibrillation. As AMI patients are extremely vulnerable to lethal heart rhythms, it’s always a good idea to
have the AED or defibrillator ready in case they are needed. 

The challenge of identifying life-threatening causes of chest pain is that diagnoses are often not easily
made in the field. The goal of the EMS professional is to take a thorough history, uncover as much
information as possible on scene with a thorough scene survey and thorough history-taking, and to
perform a complete physical exam. In addition, frequent monitoring and re-evaluations are important as
patient condition can dramatically change.

Effective History-Taking Questions With The Chest Pain Patient:

 Events preceding chest pain (Trauma? Exertion? Emotional stress?)

 Severity (How bad is your pain on a scale from 1 to 10?)
 Location (Where exactly is your pain located?)
 Radiation (Does the pain radiate to your arm, neck, or back?)
 Duration (How long did the pain last?  Is it still there?)
 Modifying factors (What made the symptoms better?)
 Exacerbating factors (What made the symptoms worse?)
 Quality (How would you describe the discomfort? Pressure? Sharp? Worse with
deep inspiration or movement?)
 Associated symptoms (Do you have any sweating or nausea? Shortness of breath? Abdominal
pain?) 
 Heart disease risk factors (i.e. smoking, family history of heart disease, diabetes, hypertension,
high cholesterol)

In the scenario you have just witnessed, our EMS crew is dispatched to the home of a 58-year-old man
complaining of sharp left anterior chest pain. The pain came on suddenly while he was at rest, sitting at
the computer, and is worse with deep inspiration, and is accompanied by mild shortness of breath.

Scene Survey,

As soon as the crew arrives on scene, the lead medic immediately calls for a thorough scene survey.
Additionally, our lead medic in this scenario kneels down, introduces him- self, and speaks in a calm and
reassuring manner. This is very important as patients with chest pain are often nervous that they are
having a heart attack. Your calm demeanor can help keep your patient calm. If you gain your patient’s
trust, you have a much higher chance of your call running more smoothly and it may help you uncover
clinically relevant information. Your priority must always be to ensure scene safety for both your patient
and your crew, and perform a thorough scene survey. Assess the patient’s ABC’s, and initiate oxygen
therapy. Conduct a thorough history and physical exam and assess the patient’s vital signs, including a
temperature.

During the scene survey, our crew member does not find anything out of the ordinary.

ABC's

Our patient's airway is clear without signs of obstruction. His breathing is unlabored with a rate of 18.
High-flow oxygen is quickly applied. Applying oxygen to all chest pain patients is usually a good idea. Our
patient's pulses are present and strong at a rate of 120.

Preliminary Diagnosis

Based on our clues of our patient having sudden left-sided chest pain that is worse with movement and
deep inspiration, all we can say is that our patient has left-sided pleuritic chest pain. We cannot come
any closer to a diagnosis without performing additional tests in a hospital setting.

Immediate Treatment

 Personal protective equipment

 Scene safety/Prevention of injury
 ABCs/Oxygen
 History
 Vital signs
 Physical examination
 Paramedic care: IV, blood sugar evaluation, 12-lead EKG

Pearls Of Wisdom

All chest pain patients should be treated as having a true medical emergency. The reason is because it is
extremely difficult if not impossible to rule-out life-threatening causes of chest pain in the field.

Myocardial infarction (MI) is typically the result of a blockage in one of the coronary arteries due to an

atherosclerotic plaque. The partial or complete blockage of this coronary blood vessel causes the lack of
oxygenated blood to be delivered to a portion of the heart causing an infarction (death of heart muscle).
As time is muscle, the quicker these patients are treated with either fibrinolytics (clot busters) or
angioplasty, the better. The goal in both treatment modalities is to open the blocked coronary artery as
soon as possible.

Is This The First Time They Have Had This Pain?

If the patient says their pain is identical to the pain they experienced previously with a collapsed lung
or pulmonary embolism, or similar to the pain when they previously had a MI, take this information very
seriously.

Chest Pain (ALS) > Causes Of Chest Pain And Common Symptoms. Beware Of Atypical Presentations!

Acute coronary syndrome (angina, myocardial infarction) – exertional chest

pressure, dyspnea, radiation to arm/neck/back 

Pulmonary embolism  – sudden onset, sharp chest pain, dyspnea 

Pneumothorax  (i.e. collapsed lung) - sharp chest pain with dyspnea 

Aortic dissection  – sudden tearing pain radiating to back 

Gastroesophageal reflux – burning sensation from upper abdomen often radiating to chest Esophageal
spasm – chest pain 

Chest wall pain/Costochondritis  – pain worse with deep inspiration, movement and palpation 

Pneumonia  – cough, fever, pleuritic chest pain, dyspnea 

Pericarditis  – pleuritic chest pain that improves with sitting upright, worse lying flat.

Coronary Artery Disease

Coronary artery disease facts: 3  

 An American has a coronary event every 25 seconds 

 Every minute, an American dies from coronary artery disease 

Misdiagnosed Heart Attacks

Misdiagnosed heart attack is one of the most common causes of malpractice litigation for emergency
department physicians. The reason for this is probably due to the high number of atypical presentations
for heart attack. Acute MI patients do not always present with the classic symptoms and the lesson here
is to be thorough with your history-taking skills. Do the patient’s symptoms get worse with exertion? Do
they improve with rest? Does the patient have risk factors for coronary artery disease? Is the patient
complaining of sweating? As always, your ability to approach each patient thoroughly and methodically
will assist you in narrowing the possibilities to explain your patient’s symptoms.

Risk Factors For the Formation Of Atherosclerosis

  Age
 Male
 Smoking
 High cholesterol
 Diabetes
 Hypertension
 Family history

Young Patients At High Risk

 Cocaine abusers
 Insulin-dependent diabetes mellitus (IDDM)
 High cholesterol levels
 Strong family history of cardiac disease at young age

Myocardial Infarctions (MI)

 1.3 million cases each year

 500,000 – 700,000 deaths from ischemic heart disease each year
 ½ of AMI deaths occur in prehospital setting
 Males at greater risk between ages 40 – 70
 Each year, 5 million patients present to Emergency Departments with chest pain

Possible Symptoms Of MI

 Chest or midepigastric discomfort

 Dyspnea (shortness of breath)
 Arm, neck, or upper back pain
 Sweating
 Nausea and/or vomiting
 Lightheadedness
 Palpitations
 Syncope
 EKG changes
 Signs of shock

Treatment Of MI In The Field

 Oxygen
 Aspirin
 Nitroglycerin (always ask about sexual enhancing medications before administering
nitroglycerin)
 Morphine
Treatment Of MI In The Hospital

 Fibrinolysis  – intravenous clot busting drug (i.e. tPA®, retavase®, TNKase®, streptokinase)

 Angioplasty  – an interventional cardiologist places a wire into the femoral artery and feeds the
wire into the aorta. Dye is then injected allowing visualization of the coronary arteries and
determination if there is a blockage. A blockage can then be opened by placing a balloon in the
blocked area and inflating it. A stent is often placed at the site of the blockage to maintain the
involved area opened. Most authorities would agree that if angioplasty can be done
immediately, it is a better option than fibrinolysis.

Atypical Presentations Of MI

 Women
 Elderly
 Diabetics

Pearls Of Wisdom

Making assumptions with the chest pain patient is a reliable method to make an error. Atypical
presentations are common and serious causes of chest pain have a lot of overlap with benign causes of
chest pain. Treat all chest pain patients seriously.

Chest Pain In The Field

Patient safety and frequent re-evaluations are the mainstays of chest pain management. 

 Maintain airway.
 Assess blood sugar (per local protocol).
 Keep patients calm.
 Administer oxygen.
 If paramedic care is available, consider aspirin, nitroglycerin, and morphine if there is a suspicion
of myocardial ischemia causing the chest pain, and there are no contraindications (check with
local policies and procedures).
 If paramedic care is available, and tension pneumothorax is suspected, perform needle
decompression (based on local policy and protocol).

Pulmonary Embolism

Complication of venous thromboembolism (i.e. venous clots), often occurring in the lower extremities. 
3rd most common cause of death in the U.S.  Common risk factors include prolonged immobilization (i.e.
long car ride or plane ride), obesity, malignancy, indwelling catheters, hypercoagulable states, and
recent surgery.

Aortic Dissection
A tear in the inner layer of the aorta causing a false lumen to occur. Blood flow then dissects into this
false lumen which can reduce blood flow to critical areas. If the dissection involves the outer layer of the
heart (i.e. pericardium), a pericardial tamponade can occur. 50% of patients with an aortic dissection will
die within 48 hour if untreated. Males are more commonly affected than females. Risk
factors include hypertension, collagen vascular diseases (i.e. Marfan syndrome), recent cardiac
catheterization, cocaine abuse, and family history.

Gastroesophageal Reflux Disease (GERD)

"Heartburn" – reflux of gastric juice from the stomach into the esophagus. 7% of people
experience symptoms of GERD daily. The important teaching point about GERD is to never assume that a
patient's symptoms are due to GERD. The symptoms of GERD overlap greatly with serious causes of
chest pain, and the assumption should always be that a patient is having a coronary event until proven
otherwise after further testing and a physician evaluation and testing.

Costcochondritis

Inflammatory process of the ribs – benign, but symptoms, can greatly overlap the symptoms of coronary
syndromes. Do not ever assume that a patient's chest pain is due to costochondritis.  A
thorough  evaluation  and transport is always recommended.

Documentation

It is important when treating the chest patient that you methodically document the history and physical
exam findings. Is the chest pain “sharp” or a “pressure”? Was it secondary to trauma? Have they had the
chest pain before? Does anything make the pain better or worse? If an EKG is performed make sure to
document your interpretation of the EKG and to not rely on the computer’s interpretation. If a 2nd EKG
or subsequent EKGs are performed, make sure to document the time they are performed and your
interpretations. If the patient has an old EKG with them, it is always a good idea to compare the old EKG
with the new one to see if there are any changes. Make sure to get a list of current medications and to
document if the patient has been compliant with their medications. Asking the right questions and
documenting the answers to those questions can be instrumental in uncovering the cause of a patient’s
chest pain.

What Happened To Our Patient?

At the Emergency Department, our patient had a CXR revealing a 30% pneumothorax on the left side. A
chest tube was placed and our patient had an uneventful hospital stay. A new spontaneous
pneumothorax occurs about 20,000 times each year in the U.S. This statistic is separate from those
patients that have a pneumothorax as a result of trauma. Overall, trauma is the most common cause of
pneumothorax. Spontaneous pneumothorax is more common in taller people, males, and
smokers. Symptoms are typically related to the size of the pneumothorax. The interesting thing about
pneumothorax is that the symptoms significantly overlap with the symptoms of chest wall pain. Over
the years, I have seen many patients in the Emergency Department that have had spontaneous
pneumothorax diagnosed on CXR that I was initially confident only had chest wall pain. The lesson here
is that chest pain is a complaint that can be caused by a myriad of possibilities, some of which are life-
threatening like a pneumothorax or aortic dissection, which can present very similarly to benign causes
of chest pain like a pulled muscle. Be thorough, make no assumptions, and take all chest pain patients
seriously.

Glossary

Alveoli  : Balloon-like clusters of single-layer air sacs that are the functional site for the exchange of
oxygen and carbon dioxide in the lungs.
Aorta  : The largest artery in the body, originating from the left ventricle.
Arteries  : The muscular, thick-walled blood vessels that carry blood away from the heart.
Body  : In the context of the uterus, the portion below the fundus that begins to taper and narrow.
Collagen  : Protein that gives tensile strength to the connective tissues of the body.
Contraindications  : In health care, conditions or factors that increase the risk involved in using a
particular drug, carrying out a medical procedure, or engaging in a particular activity.
Coronary Arteries  : The blood vessels of the heart that supply blood to its walls.
Diabetes Mellitus  : Disease characterized by the body's inability to sufficiently metabolize glucose. The
condition occurs either because the pancreas doesn't produce enough insulin or the cells don't respond
to the effects of the insulin that's produced.
Dissection  : In references to blood vessels, an aneurysm, or bulge, formed by the separation of the
layers of an arterial wall.
Drug  : Substance that has some therapeutic effect (such as reducing inflammation, fighting bacteria, or
producing euphoria) when given in the appropriate circumstances and in the appropriate dose.
Dyspnea  : Any difficulty in respiratory rate, regularity, or effort.
Evaluation  : Collection of the methods, skills, and activities necessary to determine whether a service or
program is needed, likely to be used, conducted as planned, and actually helps people.
Femoral Artery  : The main artery supplying the thigh and leg.
Illicit  : In relation to drugs, illegal drugs such as marijuana, cocaine, and LSD.
Infarction  : Death (necrosis) of a localized area of tissue caused by the cutting off of its blood supply.
Inspiration  : The active process of moving air into the lungs; also called inhalation.
Intravenous  : Within a vein.
Ischemia  : Tissue anoxia from diminished blood flow to tissue, usually caused by narrowing or occlusion
of the artery.
Ischemic  : One of the two main types of stroke; occurs when blood flow to a particular part of the brain
is cut off by a blockage (eg, a clot) inside a blood vessel.
Lead  : Any one of the conductors, composed of two or more electrodes, in the ECG that shows the
electrical conduction in the heart.
Lumen  : The inside diameter of an artery or other hollow structure.
Needle Decompression  : Also referred to as a needle thoracentesis, this procedure introduces a needle
or angiocath into the pleural space in an attempt to relieve a tension pneumothorax.
Palpation  : Physical touching for the purpose of obtaining information.
Pericardial Tamponade  : Impairment of diastolic filling of the right ventricle due to significant amounts
of fluid in the pericardial sac surrounding the heart, leading to a decrease in the cardiac output.
Pneumothorax  : The collection of air within the normally closed pleural space.
Professional  : A person who follows expected standards and performance parameters in a specific
profession.
Radiation  : Emission of heat from an object into surrounding, colder air.
Risk Factors  : Characteristics of people, behaviors, or environments that increase the chances of disease
or injury. Some examples are alcohol use, poverty, or gender.
Signs  : Indications of illness or injury that the examiner can see, hear, feel, smell, and so on.
Symptoms  : The pain, discomfort, or other abnormality that the patient feels.
Tension Pneumothorax  : A life-threatening collection of air within the pleural space; the volume and
pressure have both collapsed the involved lung and caused a shift of the mediastinal structures to the
opposite side.
Trauma  : Acute physiologic and structural change that occurs in a victim as a result of the rapid
dissipation of energy delivered by an external force.

References

1. Tintinalli, J. E. (2011). Emergency Medicine (7th ed.). New York: McGraw-Hill. 

2. Caroline, N.L. (2013). Nancy Caroline’s Emergency Care in the Streets (7th ed.). Massachusetts:
Jones and Bartlett Publishers. 
3. Alaeddini, J. (Updated 2013, April 1) [Link]. “Angina Pectoris” as retrieved
from [Link]/article/150215-overview. 
4. Zafari, A. M. (Updated 2013, May 27) [Link] “Myocardial Infarction” as
retrieved from [Link]/article/155919-overview.

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