Chest pain is one of the most common jobs that paramedics attend. Correct assessment and treatment of chest pain by paramedics (when it is caused by an acute coronary syndrome) will determine if the patient lives and how much of a quality of life the patient will have after treatment. The management of prehospital care chest pain has improved dramatically over the past 5 years, where paramedics are now able to accurately identify a STEMI through the use of a 12 Lead ECG, commence Thrombolytic Therapy (if greater than 1 hour from hospital) or transport directly to a Cardiac Catheter Lab for Angio Stenting.
Chest pain can be classified as any pain or discomfort to an area around the chest and may be related to an underlying pathology of the heart. Chest pain may be caused by a multitude of disease processes or injuries to the chest, lungs, heart, diaphragm, neck, stomach (reflux/indigestion pain) and even the abdominal organs. If in doubt about the type of chest pain, treatment should always first be targeted at the potential cardiac causes. This treatment for chest pain can then be discontinued or modified once more evidence is gathered to identify another aetiology of the chest pain.
Types of Chest Pains
Until proven otherwise, all chest pain should be considered cardiac in nature. Chest pain comes in many forms and disguises and a good clinician always considers cardiac possibilities in his or her patients. The following are common heart attack symptoms:
1. Pain to the central chest
2. Pain to the left side of the chest
3. Pain or numbness to the left arm
4. Tingling sensation down the left arm
5. Jaw pain
6. Neck pain
7. Shortness of breath during exercise or at rest
8. Sense of Impending Doom
Cardiac chest pain versus noncardiac chest pain? Simply because a person states that they have chest pain does not mean that they are having a heart attack. The exact nature or aetiology of the pain may relate to any number of medical or traumatic problems. A thorough history, taken by a good clinician with a high index of suspicion, and many diagnostic tests are the only way to determine if a person is experiencing an acute coronary syndrome (such as a heart attack) or a variety of Heart Attack Imitators. Similarly, the absence of chest pain alone, does not rule out an acute coronary syndrome, and a clinician treating any patient should have a high index of suspicion for the many manifestations of acute coronary syndrome.
According to the World Health Organisation (WHO) ‘cardiovascular disease is a major cause of disability and premature death throughout the world and contributes substantially to the escalating costs of health care’ (WHO 2011). It is therefore paramount for a patient and a clinician to suspect an acute coronary syndrome in any patient who presents with chest pain like symptoms until proven otherwise. As a paramedic, this often means treating for cardiac chest pain until you get to hospital, where more definitive cardiac diagnostic test can take place, such as blood tests, cardiac stress tests, and angiography.
Assessing Chest Pain
Newberry, Barnett and Ballard (2003, p84-5) describe a good mnemonic for assessing chest pain which may be useful for paramedics, nurses and doctors when assessing patients who may have chest pain. The following describes a good mnemonic for assessing chest pain. OPQRST is still a useful mnemonic for assessing chest pain. The mnemonic CHESTPAIN is a very good structured approach for assessing chest pain for beginning clinicians and cardiologists alike.
Paramedics assess chest pain by performing a 12 lead ECG on a patient and assessing for signs of myocardial ischemia.
In an emergency department, serial (repeated) 12 lead ECGs will be performed to assess for any acute changes in the ST segment of the ECG, and serial bloods will be taken to assess for acute changes in Cardiac Enzymes such as Troponin levels and CK/Mb levels, which may all change if a patient has had any damage to the myocardium (such as a heart attack).