My Hurting Heart

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Ok, not so much my heart as YOUR heart. And not so much your heart as your chest.

That’s right, you (my patient) are having chest pain.

The down side? I (your paramedic) immediately worry if you are having an MI (myocardial infarction), more commonly known as a heart attack.

The up side? You may get to have a very fast ride in a very loud ambulance. Admittedly that maybe that’s not everyone’s idea of an up side.

I worry that you are having an MI because that is something that can kill you quickly. I don’t like when people die on my watch. Also my attitude toward my practice is to prepare for the worst, hope for the best.

Chest pain however can be caused by a broad spectrum of pathologies and of course trauma. If you aren’t faced with a good variety on a regular basis, it’s easy to miss the subtle signs/symptoms that could point you towards a really good differential diagnosis.

So get ready for a quick and dirty review of some of the “common” causes of chest pain.

Orange=Important Clues (Keep in mind that every patient presents with their own personal twist).

MI (Myocardial Infarction)

heart-attack-420x425

Definition: the irreversible necrosis (death) of heart muscle secondary to prolonged ischemia (lack of 02)

Type of Chest Pain:

  • Intense and unremitting for 30-60 minutes
  • Retrosternal and often radiates up to the neck, shoulder, and jaw and down to the ulnar aspect of the left arm
  • Usually described as a substernal pressure sensation that also may be characterized as squeezing, aching, burning, or even sharp
  • In some patients, the symptom is epigastric, with a feeling of indigestion or of fullness and gas

Other Vital Signs/Clinical Presentation:

  • The patient’s heart rate is often increased secondary to sympathoadrenal discharge
  • The pulse may be irregular because of ventricular ectopy, an accelerated idioventricular rhythm, ventricular tachycardia, atrial fibrillation or flutter, or other supraventricular arrhythmias; bradyarrhythmias may be present (suggest impaired function of SA node)
  • In general, the patient’s blood pressure is initially elevated because of peripheral arterial vasoconstriction resulting from an adrenergic response to pain and ventricular dysfunction
  • However, with right ventricular myocardial infarction or severe left ventricular dysfunction, hypotension is seen
  • The respiratory rate may be increased in response to pulmonary congestion or anxiety
  • Coughing, wheezing, and the production of frothy sputum may occur (SOB)
  • Pale skin, diaphoresis, cyanosis
  • Anxiety
  • Altered mental status
  • Fatigue/malaise
  • Unrelieved by Nitroglycerin admin
  • 12 Lead ECG: ST elevation
  • Right Sided Infarction: JVD, Kussmal’s sign, peripheral edema, ascites, hypotension

http://emedicine.medscape.com/article/155919-clinical#a0256

PE (Pulmonary Embolism)

pe

Definition:  A pulmonary embolus is most often caused by a blood clot in a vein, especially a vein in the leg or in the pelvis (hip area). The most common cause is a blood clot in one of the deep veins of thighs. This type of clot is called a deep vein thrombosis (DVT). The blood clot breaks off and travels to the blood vessels in the lungs. Less common causes include air bubbles, fat droplets, amniotic fluid, or clumps of parasites or tumor cells, all of which may lead to a pulmonary embolus.

Type of Chest Pain:

  • Sudden onset
  • Under the breastbone or on one side
  • Most often feels sharp or stabbing
  • May also be described as a burning, aching, or dull, heavy sensation
  • Usually gets worse with deep breathing, on inhalation, or when coughing (pleuritic chest pain)

Risk Factors: Burns, Cancer, Childbirth, Family history of blood clots, Fractures of the hips or thigh bone, Heart attack, Heart surgery, Long-term bed rest or staying in one position for a long time, such as a long plane or car ride, Severe injury, Stroke, Surgery (especially orthopedic or neurological surgery), Use of birth control pills or estrogen therapy

Other Vital Signs/Clinical Presentation:

  • Sudden cough, possibly coughing up blood or bloody mucus (hemoptysis)
  • Rapid breathing
  • Tachycardia
  • Shortness of breath that starts suddenly
  • Altered LOA
  • New onset A-fib
  • Cyanosis
  • Peripheral edema
  • Hypotension

Myocarditis/Pericarditis/Cardiac Tamponade

peri

Definition: Inflammation of the heart muscle (myo) or sack surrounding the heart (peri) or fluid accumulation in the pericardial space (tamponade). I grouped them together because they are extremely difficult to differentiate in the field.

Type of Chest Pain: usually precordial or retrosternal with referral to the trapezius ridge, neck, left shoulder, or arm. Pain usually worsens on inspiration, lying flat, or moving. Often referred to as “sharp/stabbing”.

Other Vital Signs/Clinical Presentation:

  • low-grade intermittent fever
  • dyspnea/tachypnea
  • cough
  • dysphagia
  • pediatrics may present with abdominal pain 
  • tachycardia due to pain or bradycardia due to heart’s loss of room to pump
  • cyanosis
  • weak pulse
  • JVD
  • hypotension
  • pericardial friction rub on auscultation 

Pericarditis

  • ST elevation in ALL leads 
  • In tuberculous pericarditis, fever, night sweats, and weight loss are commonly noted (80%).

Tamponade:

  • Dyspnoea and orthopnoea are particularly noticeable when cardiac tamponade develops (haemodynamic changes resulting from restriction to the movement of heart muscle, secondary to pericardial effusion).
  • Patients with tamponade may exhibit the Beck triad (hypotension, elevated systemic venous pressure often with jugular venous distention, and muffled heart sounds).
  • Slowly developing tamponade may also result in pulsus paradoxus (defined as a 10 mm Hg decrease in arterial systolic pressure with inspiration).

http://www.patient.co.uk/doctor/acute-pericarditis

Pleuritis

pleural-effusion

Definition: Inflammation of the pleura (lining of the lungs)

Type of chest pain: sharp pain associated with inhalation and exhalation, “stabbing” pain

Other vital Signs/Clinical Presentation:

  • cough/SOB/dyspnea
  • fever/chills
  • chest tenderness
  • sore throat (spread to esophagus)
  • unexplained weight loss
  • pneumothorax (complication)
  • pleural effusion

http://www.pleuritis.net/

Pneumothorax (Collapsed Lung)

lung

Definition: a collection of air between the outside surface of the lung and the inside surface of the chest wall. These two surfaces are lined with a smooth membrane called pleura and normally are in contact with each other, but they can become separated when air, fluid or blood collects between them.

Type of Chest Pain: The major symptom is sudden chest pain with breathlessness. The pain may be either dull or sharp or stabbing. It begins suddenly and is worsened by breathing deeply or by coughing.

Causes: ruptured cyst or bleb, associated lung disease (emphysema being the most common), tall/thin adolescents, trauma, scuba diving/smoking (increases risk of occurence), onset of menstrual period in women (catamenial pneumothorax), pneumonia, asthma, cystic fibrosis, lung CA, prior pneumo

Vital Signs/Clinical Presentation:

  • SOB/dyspnea
  • coughing
  • cyanosis (late finding)
  • fatigue
  • tachycardia
  • nasal flaring
  • decreased/absent breath sounds over site

http://www.lung.ca/diseases-maladies/a-z/pneumothorax-pneumothorax/index_e.php

Other Chest Pain Considerations:

Hiatal Hernia: Pain gets worse when lying down

Esophageal Rupture: sudden, sever pain after vomiting or esophageal procedure

Peptic Ulcer: pain gets better after eating

Angina: improves with rest or use of medication

Pancreatitis: worse when lying flat, better when sitting forward, pain associated with lower chest

Cholecystitis (gallbladder inflammation): aggravated by consuming fatty foods, pain associated with lower chest

Gastroesophageal Reflux Disorder (GERD): can feel similar to heart pain due to location of esophagus, sour taste in mouth

Rib fracture: pain generally located in one area, increased pain on palpation, pain worsens on deep breathing or coughing

Muscle Strain: can be caused by really hard, persist coughing, pain generally worsens with activity

Shingles: can cause “band-like” pain before eruption of rash

Pneumonia: chest pain accompanied by coughing (often productive- rust or green in color), fever, chills, N/V, tachycardia, fatigue, SOB

AAA: pulsating mass/sensation in abdomen, “tearing” sensation, pain radiation to back/legs/arms as dissection progresses,  persistent pain, difference in blood pressure between bilateral extremities, stroke symptoms

4453-4478-10907-25156

More causes of chest pain:

Pulmonary Hypertenstion

Asthma

Anxiety

Mitral Valve Proplapse

Coronary Artery Dissection

Hypertrophic Cardiomyopathy

http://www.webmd.com/pain-management/guide/whats-causing-my-chest-pain

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Good luck with that!

Medic 15

P.S.- MONA LISA from our nursing friends: Morphine, Oxygen, Nitroglycerin, ASA, Listen to Heart Sounds, Intensive Care, Stat Labs, Analyze the ECG

 

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One thought on “My Hurting Heart

  1. Pingback: Caregivers Observe Assisted Living Residents For Signs Of Pain | Family & Relations Articles

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