Case_Study__Chest_Pain

Case Study 1 Patient is a 49 year old Male presenting with 5/10 crushing substernal chest pain radiating to his left arm accompanied by shortness of breath. Possible Diagnosis: Chest pain of a cardiac nature. Definition: Chest pain attributed to heart disease occurring when there is an interruption of blood flow and oxygen supply to the heart muscle. Cause: Heart disease is a process that develops over decades where the coronary arterial walls become thick and clogged with fatty deposits and loses elasticity this narrowing of the arteries can prevent a normal amount of oxygen rich blood from reaching the heart muscle and this fatty plaque can rupture and cause partial or a complete blockage of the artery. Risk factors are hypertension, smoking, high blood lipids, lack of exercise, obesity, stress, excessive alcohol consumption, male, advanced age, family history and diabetes mellitus. Signs and Symptoms: Chest pain of a cardiac nature can be describing the substernal pain as heaviness, crushing, tight, burning, painful discomfort. Radiation of the pain to neck, jaw, abdomen or arm, (left arm more common) sweating, nausea, vomiting, pallor, palpitations, the pain coming upon exertion or sudden onset at rest, dizziness, shortness of breath and a “sense of impending doom.” Signs and Symptoms of the case study patient are describing the pain as crushing at the substernal chest area, radiation of the pain to left arm, pale, cool, clammy, sudden onset of pain at rest and shortness of breath. Other causes of chest pain: Cardiovascular- Myocardial Infarct (death of the heart muscle due to blockage of the blood supply to the heart), Angina Pectoris (reduced blood flow to the heart due to coronary artery disease typically have chest pain on exertion and relieved by rest) , Aortic Aneurysm (major blood vessel rupture) Respiratory- Severe pneumonia (inflammation of the lungs most often caused by infection), Pleurisy (Inflammation of the pleura membrane which lines the chest wall and envelops the lungs), Pneumothorax (collapsed lung due to air leaking into the pleura space) Gastrointestinal- Indigestion (a feeling of fullness during a meal, uncomfortable fullness after a meal, and burning or pain in the upper abdomen), Gastric Reflux (a back flow of acid into the oesophagus which causes a burning sensation and pain in the stomach and or chest) Musculoskeletal- Strains and sprains (muscle or ligaments are over stretched causing pain and difficulty on movement) Psychiatric- Panic Attacks (are very sudden, discrete periods of intense anxiety, mounting physiological arousal, fear and physical discomfort), Anxiety (unpleasant feeling which is typically associated with uneasiness, fear or worry and can mimic a number of physical conditions) Trauma- Rib Fractures (a break or fracture in the bone(s) which form the rib cage and are the most common injury sustained following blunt chest trauma) Pleuritic Chest Pain: Pleurisy or other problems affecting the pleura membrane which lines the chest wall and envelops the lungs can cause a pleuritic chest pain. This is usually a sharp stabbing pain. The pain is made worse by breathing-in, or coughing, as this causes the two parts of the inflamed pleura to rub over each other. Signs and Symptoms of Pleuritic Chest Pain: Sharp pain, can even be described as knifelike usually lower lateral area of chest. Coughing and deep breathing generally make pain worse. Decreased breath sounds, inspiratory crackles and pleural friction rub may be heard on auscultation. Difficulty breathing, rapid, shallow breathing, cyanosis, a fever and fatigue. Unfamiliar Terms Hyperlipidemia: Raised or abnormal levels of lipids (fat) in the blood Substernal: Situated beneath the sternum What factors may be causing chest pain in this patient and the specific information which aided the decision of chest pain of cardiac nature as a possible diagnosis. Past History: 2 pack/day smoker Diabetes Mellitus Hyperlipidemia Obesity Family History Coronary Artery Disease History: Patient has been awakened from his sleep with crushing substernal chest pain which radiates to his left arm and accompanied by shortness of breath. O/E: 49 y.o male C/O 5/10 crushing substernal chest pain, radiating to left arm CNS GCS=14 PSA BP=90/60, HR=50, Skin= Cool, Pale, Clammy RSA RR=26 S.O.B After transporting the patient to hospital At destination: 49 y.o male C/O 5/10 crushing substernal chest pain, radiating to left arm now in considerable distress CNS GCS=14 PSA BP=80/60 decreased, HR=45 decreased, Skin= Cool, Pale, Clammy RSA RR=26 S.O.B, decreased breath sounds with occasional expiratory wheezes Factors and Summary: Patient past history gives multiple risk factors for causes of heart disease. The pain description by the patient fits symptoms of being cardiac in nature using the DOLOR mnemonic to assess pain Description- Crushing, 5/10 pain score (Verbal pain rating score 0-10) Onset- Sudden onset, awakened from his sleep Location- Substernal, radiating to his left arm Other symptoms- Shortness of breath, Skin pale, cool, clammy Relief-unknown for this Patient but questioning patient if they have made any attempt to relieve the pain and has it made it better or worse or no change Patient vital signs survey indicates inadequate perfusion. His BP and Pulse are below normal range, his skin is cool, pale and clammy another sign of inadequate perfusion and his GCS of 14 could be that he is hypoxic and or his pre existing diabetes is at a low blood sugar level. Observations criteria for normal adult range: Perfusion Status Assessment Blood Pressure >100mmHg systolic Pulse Rate 60-100 beats per minute Skin Colour, temperature (Use thermometer), moistness Warm/Pink/Dry Conscious State using Glasgow Coma Score Max score 15 Alert and Orientated in time and place The bodies’ ability to provide adequate oxygenated blood supply to vital organs and effectively remove metabolic waste has been compromised due to his poor perfusion. His decreased venous return decreases his cardiac output. The blood pressure and heart rate have dropped so now the blood supply has become less oxygenated the bodies response is to compensate by constricting the vascular bed and increasing the heart rate. The body reaches its limit of compensating and then starts to decompensate as this Patient’s observations show and so the brain sends off signals to increase the respiratory rate in the hope to increase oxygen to the blood supply. The patient increased respiratory rate of 26 breaths per minute (normal range12-16 breaths per/min) and shortness of breath would be increasing his distress further increasing the oxygen demand on his heart hence continued chest pain. This patient would look sick. The last set of observations taken alert me to the fact he is getting worse and on a downward spiral his bradycardia is a warning sign of server hypoxemia and I think he is in an imminent life threat of cardiac arrest. With absent breath sounds and occasional expiratory wheeze, altered conscious state still cool pale and clammy and obvious distress he may have Acute Pulmonary Oedema also adding to his presentation. Emergency Treatment of this Patient | |Ambulance Management |NEPT Management |Difference between the | | | | |Emergency/ | | | | |NEPT sectors Treatments | | | | | | |Initial Management |-rest and reassurance position of |-rest and reassurance position of comfort|Initial management the same | | |comfort | |for both sectors | | |- Explain to patient what you are doing |- Explain to patient what you are doing | | | |and why. |and why. | | | |-Obtain key history. |-Assess pain using | | | |-Assess main presenting problem “Chest |DOLOR is chest pain of cardiac nature' | | | |Pain-Cardiac in Nature” |Determine pain severity using | | | |-Administer OXYGEN via face mask 8l/min |Verbal pain rating score (0-10) | | | |initially |-Administer OXYGEN- CPP p.46 via face | | | |- Attach and assess with cardiac monitor|mask 8l/min initially, | | | |record 3 leads and attach pulse oximeter| | | | | | | | |Determine if Patient is |-Assess physiological status Vital Signs|-Assess physiological status Vital Signs |- ‘Emergency patients’ under | |Treatment/or Transport |Survey (VSS) |Survey (VSS) |NEPT CPP p.9 must not be | |Time Critical |Perfusion Status Assessment |Perfusion Status Assessment (PSA) CPP |transported. Contact | | |(PSA)CPG:A0102 |p.23 |Emergency communications | | |Respiratory Status Assessment (RSA) |Respiratory Status Assessment (RSA) CPP |centre and await further | | |CPG:A0103 |p.22 |instruction. | | |Conscious state (GCS) CPG:A0104 |Conscious state (GCS)CPP p.21 | | | |- Assess pattern of Injury/Illness |- Assess pattern of Injury/Illness |- Emergency Ambulances can | | |- Assess mechanism of injury/illness |- Assess mechanism of injury/illness |provide more definitive care | | |Manage as “TIME CRITICAL”-Actual |- If likely to be cardiac pain or | | | |CPG:A0101 At the time the VSS was taken |discomfort |- CPP stands for Clinical | | |the patient was in actual physiological |- Contact Emergency ambulance Service |Practice Protocols in the | |Determine if Patient is |distress-Physiological signs not in |(000) |NEPT sector | |Treatment/or Transport |NORMAL range |- This patient is an adult emergency |CPG stands for | |Time Critical cont…. | |patient as defined in the NEPT |Clinical Practice Guidelines | | |-Provide Situation Report |CPP p.9 and fits the following |in the Ambulance sector both | | |o Op-Cen. Patient age, gender |signs/symptoms/clinical |provide | | |M- Main presenting problem |syndromes defined as an emergency patient|knowledge, education and | | |I- Illness Past history |who |training in clinical | | |S- Signs, symptoms, VSS |may not be transported by NEPT |instruction and clinical | | |T- Treatment/response to treatment |BP2 and sublingual GTN CPP-|the same. | | |- The administration of GLYCERYL |p.41 contraindicated (BP < 110mmHG) which| | | |TRINITRATE 0.6mg tablet CPG:D013 is to |it is for this Patient | | | |be considered as it is a vascular smooth|- Administer METHOXYFLURANE | | | |muscle relaxant to aid in the reduction |3 ml CPP-p.45 If Pain score >2. Used for | | | |of the myocardial oxygen |pre-hospital pain relief via Penthrox | | | |demand the effects also reduce blood |inhaler with oxygen if no | | | |pressure |contraindications. | | | |2 contraindications exist for the |- Repeat METHOXYFLURANE 3 ml CPP-p.45 | | | |administration of GLYCERYL TRINITRATE |after 25 minutes if pain score remains >2| | | |0.6mg CPG:D013 for this patient due to | | | | |Patient BP being below 110mmHg and his | | | | |pulse of 50 bpm being bradycardic | | | | |-Administration of MORPHINE SULPHATE | | | | |10mg CPG:D022 is a narcotic analgesic, | | | | |if no known hypersensitivity, to be | | | | |given in increments up to 5 mg IV based | | | | |on patient needs for the relief of pain.| | | | |If necessary repeated doses up to 5mg IV| | | | |can be given every 5 minutes until pain | | | | |score is 2 or less or maximum of 20mg | | | | |administered. | | | | | | | | |Ongoing Management |-Reassess Patient after each |- Be advised by the Emergency |- The Emergency | | |administration of medication given, |Communications Centre for instruction on |Communications Centre | | |record time medication administered, |transport of this Patient and follow as |performs the role of matching| | |dose, route and effect/response to |instructed. |patient condition to most | | |treatment |- Continually reassess patient during |qualified skilled person/s to| | |- Identify actual or potential problems,|transport and or waiting for Emergency |manage the condition of the | | |possibility of cardiac arrest and the |Ambulance and modify treatment as |patient. | | |need for CPR. |required |- The NEPT sector is designed| | |- Be aware that any excessive effort on |- Notify Emergency Communications Centre |to transport 3 Groups of | | |the patient part may exacerbate |if patient condition deteriorates |non-emergency patient the | | |condition. Control patient’ workload by |- Identify actual or potential problems, |Low-acuity, Medium- | | |having appropriate |possibility of cardiac arrest and the |acuity and High-acuity | | |equipment to load patient to ambulance |need for CPR. |Patient. Each group also has | | |stretcher with out patient having to |- Be aware that any excessive effort on |a minimum staffing level who | | |walk. |the patient part may exacerbate |are authorized to | | |- If patient willing to accept bag valve|condition. Control patient’ workload by |practice at different levels | | |mask delivery of OXYGEN which provides |having appropriate equipment to load |- The Ambulance sector has | | |60%-95% concentration administer and |patient to ambulance stretcher with out |varying skill base levels of | | |reassess |patient having to |staffing for example BLS | | |- Perform a Random |walk. |Paramedics, ALS Paramedics | | |Blood glucose analysis RBG CPG:A0801 |- If patient willing to accept bag valve |and MICA Paramedics but all | | |because Patient has a history of |mask delivery of OXYGEN which provides |are highly qualified in | | |Diabetes and GCS of 14 to evaluate blood|60%-95% concentration CPP p.46 administer|emergency care with varying | | |glucose level to exclude hypoglycemia |and reassess |levels of qualifications to | | |- Thought of raising lower limbs on |- If transporting to destination/ |treat. | | |stretcher to Auto-infuse the blood from |Ambulance crew notify receiving facility | | | |the extremities, to raise the blood |using | | | |pressure and fill vessels in the vital |IMISTA CPP p.40 | | | |organs because Patient BP is below |I- Introductory information, Patient age,| | | |100mmHg but the “pay off” is to | | | | |have patient on stretcher |gender | | | |in the sitting upright position due to |M- Main presenting problem | | | |breathing difficulties as lying |I- Illness Past history | | | |flat/semi reclined will worsen Patient |S- Signs, symptoms, VSS |- Mnemonic differs slightly | |Ongoing Management cont… |condition. |T- Treatment/response to treatment |between the two sectors but | | |-Commence transport as |A- Any other relevant information |essentially the same | | |appropriate | |information is relayed to the| | |- Notify receiving hospital of your | |receiving facility | | |patient condition and relevant | | | | |information using | | | | |MIST-Pre-arrival notification and | | | | |estimated time of arrival. | | | | |-Ongoing reassessment | | | | |- Handover to receiving Hospital | | |