Chest Pain Differential Diagnosis. Region VIII EMS Systems January 2015

Transcription

1 Chest Pain Differential Diagnosis Region VIII EMS Systems January

2 Introduction SME video of the month Review of Cardiac SOPs Three scenarios Review Amiodarone Administration IV piggyback 2

3 Differential Diagnosis of Chest Pain Common Causes of Chest Pain Cardiovascular: ischemia- AMI or angina, pericarditis, thoracic aortic dissection Respiratory: PE, pneumothorax, pneumonia, and pleural irritation Gastrointestinal: cholecystitis, pancreatitis, hiatal hernia, esophageal disease, GERD, peptic ulcers, and dyspepsia Musculoskeletal: chest wall syndrome, costochondritis, herpes zoster, chest wall trauma, and chest wall tumors Psychological: Hyperventilation, anxiety 3

4 DIFFERENTIAL DX OF CHEST PAIN CAUSE ONSET OF PAIN CHARACTERISTIC OF PAIN LOCATION OF PAIN HISTORY ASSOCIATED SX/SX AGGRAVATING FACTORS RELIEVING FACTORS 4

5 CAUSES Angina Myocardial Infarction Dissecting Aneurysm Pericarditis Pneumonia Pneumothorax Pulmonary Embolism GI Disturbance Hiatal Hernia Hyperventilation or Anxiety 5

6 ONSET / DURATION OF PAIN Sudden Gradual Lasts Minutes Lasts Hours Varies 6

7 QUALITY PLEURITIC SPASMODIC TIGHTNESS OR HEAVINESS PRESSURE - OPPRESSIVE SHARP / LOCALIZED / VISCERAL / BURNING TEARING / EXCRUCIATING 7

8 LOCATION SUBSTERNAL CENTER OR ACROSS CHEST LATERAL CHEST LOCALIZED OVER INVOLVED AREA LOWER CHEST / EPIGASTRIC RADIATES TO JAW, NECK, BACK OR ARM VAGUE 8

9 HISTORY AGE PREVIOUS EPISODES UPPER RESPIRATORY INFECTION / FEVER TRAUMA STRESS EMOTIONAL UPSET CARDIAC DISEASE HTN, CAD, ANGINA PHLEBITIS 9

10 ASSOCIATED SIGNS / SYMPTOMS DYSPNEA NAUSEA / VOMITING RASH OR LESIONS DIAPHORESIS HEMOPTYSIS CYANOSIS HYPOTENSIVE HYPERTENSIVE UNEQUAL BP NEURO CHANGES PULSATING ABD MASS AMS / WEAKNESS / LIGHTHEADEDNESS / SYNCOPE 10 DECREASED OR ABNORMAL BREATH SOUNDS ABDOMINAL PAIN

11 AGGRAVATING FACTORS BREATHING MOVEMENT STRESS EXERTION AFTER EATING OR ETOH LAYING DOWN SITUATIONAL / ANXIETY 11

12 RELIEVING FACTORS REST OR DECREASED MOVEMENT POSITION SITTING UP OR LEANING FORWARD DECREASED OR SHALLOW BREATHING DIET ANTACIDS MEDICATIONS 12

13 Differential Diagnosis of Chest Pain Cardiovascular Respiratory Gastrointestinal Musculoskeletal Psychological 13

14 O P Q R S T Onset Provokes, Palliates Quality Region, Radiation Severity Time Sudden Gradual Breathing Movement Stress Exertion After eating or ETOH Laying down Situational / anxiety Rest or decreased movement Sitting up or leaning forward Decreased or shallow breathing Diet Antacids Medications Pleuritic Spasmodic Tightness or Heaviness Pressure Oppressive Sharp/Localized Visceral/Burning Tearing/Excruciating Substernal Center or across chest Lateral chest Localized over involved area Lower chest / epigastric Radiates to jaw, neck, back or arm Vague # on 0 10 scale Mild Moderate Severe Similar / Worse than previous episodes Lasts Minutes Lasts Hours Varies History Other Associated Symptoms Age Previous episodes Upper respiratory infection/fever Trauma Stress Emotional upset Cardiac disease HTN, CAD, angina Phlebitis Dyspnea Diaphoresis Nausea / Vomiting Neuro Changes AMS / Weakness / Lightheadedness / Syncope Hypo Or Hypertension Or Unequal BP Increased, Decreased Or Abnormal Breath Sounds Hypoxia, Cyanosis Hemoptysis Abdominal Pain, Pulsating Abd Mass JVD Vesicular 14 Pain With Palpation Rash Or Lesions

15 Differential Diagnosis of Chest Pain Cardiovascular Respiratory Gastrointestinal Musculoskeletal Psychological 15

16 Angina 16

17 O P Q R S T Onset Provokes, Palliates Quality Region, Radiation Severity Time Sudden Gradual Breathing Movement Stress Exertion After eating or ETOH Laying down Situational / anxiety Rest or decreased movement Sitting up or leaning forward Decreased or shallow breathing Diet Antacids Medications Pleuritic Spasmodic Tightness or Heaviness Pressure Oppressive Sharp/Localized Visceral/Burning Tearing/Excruciating Substernal Center or across chest Lateral chest Localized over involved area Lower chest / epigastric Radiates to jaw, neck, back or arm Vague # on 0 10 scale Mild Moderate Severe Similar / Worse than previous episodes Lasts Minutes Lasts Hours Varies History Other Associated Symptoms Age Previous episodes Upper respiratory infection/fever Trauma Stress Emotional upset Cardiac disease HTN, CAD, angina Phlebitis Dyspnea Diaphoresis Nausea / Vomiting AMS / Weakness / Lightheadedness / Syncope Neuro Changes Hypo Or Hypertension Or Unequal BP Decreased Or Abnormal Breath Sounds Cyanosis Hemoptysis Pulsating Abd Mass Abdominal Pain Vesicular Pain With Palpation Rash 17 Or Lesions

18 Acute Myocardial Infarction 18

19 O P Q R S T Onset Provokes, Palliates Quality Region, Radiation Severity Time Sudden Gradual Breathing Movement Stress Exertion After eating or ETOH Laying down Situational / anxiety Rest or decreased movement Sitting up or leaning forward Decreased or shallow breathing Diet Antacids Medications Pleuritic Spasmodic Tightness or Heaviness Pressure Oppressive Sharp/Localized Visceral/Burning Tearing/Excruciating Substernal Center or across chest Lateral chest Localized over involved area Lower chest / epigastric Radiates to jaw, neck, back or arm Vague # on 0 10 scale Mild Moderate Severe Similar / Worse than previous episodes Lasts Minutes Lasts Hours Varies History Other Associated Symptoms Age Previous episodes Upper respiratory infection/fever Trauma Stress Emotional upset Cardiac disease HTN, CAD, angina Phlebitis Dyspnea Diaphoresis Nausea / Vomiting AMS / Weakness / Lightheadedness / Syncope Neuro Changes Hypo Or Hypertension Or Unequal BP Decreased Or Abnormal Breath Sounds Cyanosis Hemoptysis Pulsating 19 Abd Mass Abdominal Pain

20 Pericarditis 20

21 O P Q R S T Onset Provokes, Palliates Quality Region, Radiation Severity Time Sudden Gradual Breathing Movement Stress Exertion After eating or ETOH Laying down Situational / anxiety Rest or decreased movement Sitting up or leaning forward Decreased or shallow breathing Diet Antacids Medications Pleuritic Spasmodic Tightness or Heaviness Pressure Oppressive Sharp/Localized Visceral/Burning Tearing/Excruciating Substernal Center or across chest Lateral chest Localized over involved area Lower chest / epigastric Radiates to jaw, neck, back or arm Vague # on 0 10 scale Mild Moderate Severe Similar / Worse than previous episodes Lasts Minutes Lasts Hours Varies History Other Associated Symptoms Age Previous episodes Upper respiratory infection/fever Trauma Stress Emotional upset Cardiac disease HTN, CAD, angina Phlebitis Dyspnea paradoxical pulse Diaphoresis Nausea / Vomiting AMS / Weakness / Lightheadedness / Syncope Neuro Changes Hypo Or Hypertension Or Unequal BP Decreased Or Abnormal Breath Sounds Cyanosis Hemoptysis Pulsating 21 Abd Mass Abdominal Pain

22 Dissecting Aneurysm 22

23 O P Q R S T Onset Provokes, Palliates Quality Region, Radiation Severity Time Sudden Gradual Breathing Movement Stress Exertion After eating or ETOH Laying down Situational / anxiety Rest or decreased movement Sitting up or leaning forward Decreased or shallow breathing Diet Antacids Medications Pleuritic Spasmodic Tightness or Heaviness Pressure Oppressive Sharp/Localized Visceral/Burning Tearing/Excruciating Substernal Center or across chest Lateral chest Localized over involved area Lower chest / epigastric Radiates to jaw, neck, back or arm Vague # on 0 10 scale Mild Moderate Severe Similar / Worse than previous episodes Lasts Minutes Lasts Hours Varies History Other Associated Symptoms Age Previous episodes Upper respiratory infection/fever Trauma Stress Emotional upset Cardiac disease HTN, CAD, angina Phlebitis Dyspnea Diaphoresis Nausea / Vomiting AMS / Weakness / Lightheadedness / Syncope Neuro Changes Hypo Or Hypertension Or Unequal BP Decreased Or Abnormal Breath Sounds Cyanosis Hemoptysis Pulsating Abd Mass Abdominal Pain Vesicular Pain With Palpation Rash 23 Or Lesions

24 Differential Diagnosis of Chest Pain Cardiovascular Respiratory Gastrointestinal Musculoskeletal Psychological 24

25 Pneumothorax 25

26 O P Q R S T Onset Provokes, Palliates Quality Region, Radiation Severity Time Sudden Gradual Breathing Movement Stress Exertion After eating or ETOH Laying down Situational / anxiety Rest or decreased movement Sitting up or leaning forward Decreased or shallow breathing Diet Antacids Medications Pleuritic Spasmodic Tightness or Heaviness Pressure Oppressive Sharp/Localized Visceral/Burning Tearing/Excruciating Substernal Center or across chest Lateral chest Localized over involved area Lower chest / epigastric Radiates to jaw, neck, back or arm Vague # on 0 10 scale Mild Moderate Severe Similar / Worse than previous episodes Lasts Minutes Lasts Hours Varies History Other Associated Symptoms Age Previous episodes Upper respiratory infection/fever Trauma Stress Emotional upset Cardiac disease HTN, CAD, angina Phlebitis Spontaneous Dyspnea Diaphoresis Nausea / Vomiting AMS / Weakness / Lightheadedness / Syncope Neuro Changes Hypo Or Hypertension Or Unequal BP Decreased Or Abnormal Breath Sounds Cyanosis Hemoptysis Pulsating Abd Mass Abdominal Pain Vesicular Pain With Palpation Rash Or Lesions 26

27 Pulmonary Embolism 27

28 O P Q R S T Onset Provokes, Palliates Quality Region, Radiation Severity Time Sudden Gradual Breathing Movement Stress Exertion After eating or ETOH Laying down Situational / anxiety Rest or decreased movement Sitting up or leaning forward Decreased or shallow breathing Diet Antacids Medications Pleuritic Spasmodic Tightness or Heaviness Sharp/Localized Visceral/Burning Tearing/Excruciating Substernal Center or across chest Lateral chest Localized over involved area Lower chest / epigastric Radiates to jaw, neck, back or arm Vague # on 0 10 scale Mild Moderate Severe Similar / Worse than previous episodes Lasts Minutes Lasts Hours Varies History Other Associated Symptoms Age Previous episodes Upper respiratory infection/fever Trauma Stress Emotional upset Cardiac disease HTN, CAD, angina Phlebitis Smoking, Recent Surgery, BCP Dyspnea Diaphoresis Nausea / Vomiting Neuro Changes AMS / Weakness / Lightheadedness / Syncope Hypo Or Hypertension Or Unequal BP Increased, Decreased Or Abnormal Breath Sounds Hypoxia, Cyanosis Hemoptysis Abdominal 28 Pain, Pulsating Abd Mass JVD

29 Pneumonia / Pleurisy 29

30 O P Q R S T Onset Provokes, Palliates Quality Region, Radiation Severity Time Sudden Gradual Breathing Movement Stress Exertion After eating or ETOH Laying down Situational / anxiety Rest or decreased movement Sitting up or leaning forward Decreased or shallow breathing Diet Antacids Medications Pleuritic Spasmodic Tightness or Heaviness Pressure Oppressive Sharp/Localized Visceral/Burning Tearing/Excruciating Substernal Center or across chest Lateral chest Localized over involved area Lower chest / epigastric Radiates to jaw, neck, back or arm Vague # on 0 10 scale Mild Moderate Severe Similar / Worse than previous episodes Lasts Minutes Lasts Hours Varies History Age Previous episodes Upper respiratory infection/fever Trauma Stress Emotional upset Cardiac disease HTN, CAD, angina Phlebitis Other Associated Symptoms Dyspnea Diaphoresis Nausea / Vomiting AMS / Weakness / Lightheadedness / Syncope Neuro Changes Hypo Or Hypertension Or Unequal BP Increased or Decreased RR Increased, Decreased Or Abnormal Breath Sounds Cyanosis Hemoptysis / productive cough Abdominal Pain, Pulsating Abd Mass JVD Vesicular Pain With Palpation 30 Rash Or Lesions

31 Differential Diagnosis of Chest Pain Cardiovascular Respiratory Gastrointestinal Musculoskeletal Psychological 31

32 Hiatal Hernia 32

33 Gastrointestinal 33

34 O P Q R S T Onset Provokes, Palliates Quality Region, Radiation Severity Time Sudden Gradual Breathing Movement Stress Exertion After eating or ETOH Laying down Situational / anxiety Rest or decreased movement Sitting up or leaning forward Decreased or shallow breathing Diet Antacids Medications Pleuritic Spasmodic Tightness or Heaviness Pressure Oppressive Sharp/Localized Visceral/Burning Tearing/Excruciating Substernal Center or across chest Lateral chest Localized over involved area Lower chest / epigastric Radiates to jaw, neck, back or arm Vague # on 0 10 scale Mild Moderate Severe Similar / Worse than previous episodes Lasts Minutes Lasts Hours Varies History Other Associated Symptoms Age Previous episodes Upper respiratory infection/fever Trauma Stress Emotional upset Cardiac disease HTN, CAD, angina Phlebitis Dyspnea Diaphoresis Nausea / Vomiting AMS / Weakness / Lightheadedness / Syncope Neuro Changes Hypo Or Hypertension Or Unequal BP Decreased Or Abnormal Breath Sounds Cyanosis Hemoptysis Pulsating Abd Mass Abdominal Pain Vesicular 34 Pain With Palpation Rash Or Lesions

35 Differential Diagnosis of Chest Pain Cardiovascular Respiratory Gastrointestinal Musculoskeletal Psychological 35

36 Hyperventilation / Anxiety 36

37 O P Q R S T Onset Provokes, Palliates Quality Region, Radiation Severity Time Sudden Gradual Breathing Movement Stress Exertion After eating or ETOH Laying down Situational / anxiety Rest or decreased movement Sitting up or leaning forward Decreased or shallow breathing Diet Antacids Medications Decrease anxiety Pleuritic Spasmodic Tightness or Heaviness Pressure Oppressive Sharp/Localized Visceral/Burning Tearing/Excruciating Vague/Diffuse Substernal Center or across chest Lateral chest Localized over involved area Lower chest / epigastric Radiates to jaw, neck, back or arm Vague # on 0 10 scale Mild Moderate Severe Similar / Worse than previous episodes Lasts Minutes Lasts Hours Varies History Other Associated Symptoms Age Previous episodes Upper respiratory infection/fever Trauma Stress Emotional upset Cardiac disease HTN, CAD, angina Phlebitis Dyspnea Diaphoresis Nausea / Vomiting AMS / Weakness / Lightheadedness / Syncope Neuro Changes / Numbness extremities/face / carpopedal spasm Hypo Or Hypertension Or Unequal BP Decreased Or Abnormal Breath Sounds Cyanosis Hemoptysis Pulsating Abd Mass Abdominal Pain Vesicular Pain With Palpation Rash Or Lesions Increased RR 37

38 DIFFERENTIAL DX OF CHEST PAIN CAUSE ONSET OF PAIN CHARACTERISTIC OF PAIN LOCATION OF PAIN HISTORY PAIN WORSENED BY PAIN RELIEVED BY OTHER ACUTE MI Sudden onset, Pressure, burning, aching, across chest, may years, movement, anxiety NOT Relieved- no moshortness of breath, duration >30-60 mins. tightness, choking radiate to jaw and neck, may or maynot have position or breathing diaphoresis, anxiety, down arms and back hx of angina Medication-MS weakness Angina sudden onset, lasts aches, squeezing, choking, substernal,may radiate to Hx of angina, circum- lying down, eating, stressrest, oxygen, nitro unstable anginaminutes heaviness, burning jaw, neck, arms or back stances precipitating, cold weather, exertion, appears at rest pain characteristics, anger relieved by nitro Dissecting sudden onset excruciating, tearing pain center of the chest, radiate non-specific, pain nothing BP difference betwee Aneurysm into the back or abdomen usually worse at onset R & L arms Pericarditis most common- suddensharp, knife-like retrosternal, may radiate Hx of URI or fever deep breats, chest move-sitting upright, leanin friction rub, paradoxic onset to the neck & left arm ment, swallowing forward pulse Pneumothorax sudden onset tearing, pleuritic lateral chest (AS) no hx-spontaneous respiration dyspnea, increased HR chest trauma chest wall movement decreased BS, trachea deviation (UAS) Pulmonary Embolussudden onset crushing-most common lateral chest phlebitis, a fib respiration holding breath cyanosis, dyspnea, can mimic AMI or anginal smoking, BCP, post sur- hemoptysis gical, prolonged inactivity "impending doom" Hiatal hernia sudden onset sharp, severe lower chest, upper abdomemay or maynot be heavy meals, supine mild activity (walking), present position bland diet, antacids, semi-fowlers or sitting upright Gastrointestinal sudden onset gripping, burning, spasmodi lower substernal, upper may or maynot be eating or ETOH, supine antacids, bland diet or constant abdomenal present position 38

39 Leads, Leads and More Leads The question is. where does this lead us? 39

40 The Normal 12-Lead 40

41 41

42 Reciprocal Changes Region of ST Elevation Region of ST Depression Anterior (leads V1-V4) Inferior (leads II, III, avf) Inferior II, III, AVF (true posterior) Anterior (leads V1-V3) or lateral (lead 1, avl) Lateral ( leads I, avf, V5, V6) Inferior ( leads II, III, avf) True Posterior Anterior (leads V1-V3) 42

43 Copyright 2001 American Heart Association 43

44 ST-Elevation & Infarct Location Lead Location of Infarction Coronary Artery Involved II, III, avf Inferior wall (most common) Right V1, V2 Septal wall Left LAD V3, V4 Anterior wall (most lethal) Left LAD I, avl, V5, V6 Lateral wall Left CIRCUMFLEX 44

45 Anterior Leads 45

46 46 Copyright 2001 American Heart Association

47 47 Copyright 2001 American Heart Association

48 48

49 49

50 Lateral Leads 50

51 51 Copyright 2001 American Heart Association

52 52

53 Pre Intervention Post Intervention 53

54 Inferior Leads 54

55 55 Copyright 2001 American Heart Association

56 56

57 57

58 Pre PCI Post PCI 58

59 ST elevation in Inferior Leads II, III & avf 59

60 Inferiolateral Leads 60

61 True Posterior Leads Reciprocal Changes 61

62 62

63 Treat The Patient Not The Monitor If the patient s symptoms do not match the ECG, you need to do more detective work ECG is nondiagnostic in ~ 50% of patients with chest discomfort 63

64 SCENARIO 1 64

65 Caller states he needs an ambulance for a man not feeling well Questions? Address Callback Number Problem Status Fever with the nausea? History of travel Answers 234 Main St year old man with nausea and discomfort in his lower chest Conscious, alert, breathing Not warm to touch No travel to West Africa 65

66 Dispatch / Agency Protocol What vehicles get dispatched? What is the dispatch text? No ALS available from your agency, so BLS crew is dispatched ALS mutual aid ambulance will be delayed 10 minutes due to adverse weather / road conditions 66

67 BLS Assessment GCS 15 Airway - open Breathing - unlabored Circulation radial pulse strong / regular O 15 minutes ago, after eating bacon-wrapped jalapeno peppers P no provocation or palliation Q stabbing R Retro-xyphoid and across upper quadrants S 7/10, constant T 15 minutes 67

68 BLS Treatment Initial Medical Care Position of comfort Oxygen? Vitals Handoff to ambulance crew 68

69 Normal EKG Electrode Placement BLS SKILL REVIEW 69

70 SCENARIO 2 70

71 Dispatch Dispatched to a single family residence Man with chest pain and difficulty breathing Conscious Breathing BLS Engine (closer) and ALS Ambulance (from the other side of your district) are sent 71

72 BLS Arrives, Assessment Conscious, GCS 15 Airway Patent Breathing Labored Circulation Slow, weak radial pulse Complaint chest pain, short of breath O Approximately 30 minutes earlier P Started while Bears game interrupted by satellite outage, unrelieved Q Squeezing, like a Vice Grips R Retrosternal, radiating to L neck / jaw / shoulder S 9/10 72 T 30 minutes, constant

73 BLS Assessment (cont d) S As described A Allergic to codeine M Atorvastatin 40mg, aspirin 162mg, Lisinopril 10mg, metoprolol 50mg, vitamin P AMI 2/06 with stent, another stent in 2009, high cholesterol L Took medication 4 hours ago E As described Skin pale, normal, diaphoretic Pupils PERL 5mm BP 142/90 P 52 regular R 16 normal Lungs clear 73

74 BLS Treatment Position of comfort (sitting in living room chair) Oxygen how much? Aspirin how much? BLS report to ALS Ambulance crew 74

75 ALS Assessment SpO2 on low FiO2 = 99% 12-lead What does the 12-lead show? 75

76 ALS Treatment BLS has given an additional 162 mg of patient aspirin Oxygen at low FiO2 already in place NTG with Inferior Wall Myocardial Infarction? Fentanyl? Transport where? 76

77 MEDICATION OF THE MONTH BETA ADRENERGIC RECEPTOR BLOCKING SLOW CALCIUM CHANNEL BLOCKING FAST SODIUM CHANNEL BLOCKING 77

78 Amiodarone Acts directly on all cardiac tissues Prolongs duration of action potential and refractory period Decreases peripheral vascular resistance Increases coronary blood flow Blocks effects of sympathetic stimulation Controls ventricular and supraventricular arrhythmias 78

79 Amiodarone Do not use in presence of cardiogenic shock, severe sinus bradycardia or advanced AV block Continuous monitoring as drug has unusually long half life Enhances the effects of anticoagulants 79

80 80

81 81

82 ABC, HEART BLOCKS CARDIAC RHYTHM OF THE MONTH 82

83 83

84 First Degree - Delay in conduction Second Degree - Some impulses blocked Type I and II Third Degree - All impulses blocked 84

85 First Degree AV Block ECG Criteria Rate - Dependent on underlying rhythm Interpretation must include underlying rhythm Rhythm - Dependent on underlying rhythm P-Waves - Normal morphology with one P-Wave for each QRS PRI - >.20 seconds and constant QRS - Dependent on underlying rhythm 85

86 Second Degree AV Blocks Type I Wenckebach Mobitz I Type II Mobitz II 86

87 Second Degree AV Block, Type I Wenckebach Rate - Atrial rate unaffected but ventricular rate is less than atrial rate Rhythm - Atrial rhythm usually regular. Ventricular rhythm is irregular with more P-Waves than QRS Complexes. P-Waves - Unaffected with more P-Waves than QRS Complexes PRI - Progressively increases for consecutively conducted P-Waves until QRS Complex is dropped QRS Unaffected Long, longer, longer, drop! Long, longer, longer, drop! 87

88 Second Degree AV Block, Type II ECG Criteria Rate - Atrial rate is unaffected but ventricular rate is less than atrial Rhythm - Atrial rhythm regular, Ventricular irregular with more P- waves than QRS Complexes P-Waves - Normal morphology with more P-Waves than QRS Complexes PRI - Constant for consecutively conducted P-Waves QRS - Usually wide but may be narrow if block is at His level or above 88

89 Third Degree AV Block ECG Criteria Rate - Atrial > 60, Ventricular based on escape Rhythm - Atrial and ventricular regular P-Waves - Normal PRI - No association between P-Waves and QRS complexes (P s and QRS s are divorced and do their own thing) QRS - Narrow if intranodal, Wide if infranodal 89

90 ALS SCENARIO 3 90

91 Dispatch Parking lot of a local church Elderly male unresponsive EMD is instructing caller in CPR Police (AED-equipped) also responding What assets does your agency deploy? 91

92 Enroute Information Police on the scene Deploying AED No shock advised 92

93 On Scene Scene safe Police and passerby EMT alternating turns at CPR ALS Ambulance arrives first 93

94 Initial Treatment CPR continues with Police and Bystander Ambulance crew attaches defib pads (if AED pads incompatible) Complete (3 rd Degree) Heart Block, PEA Priorities Continuous High Quality CPR Vascular access Secure patent airway to ventilate Move patient inside ambulance (20 F ambient temperature) Treatable contributing causes 94

95 Treatable Causes Possible Cause What Do You Look For? Field Treatment Hypovolemia Flat veins when supine, poor skin turgor IV fluid boluses Hypoxemia Probable considering condition Increase FiO2, confirm airway placement and ventilator efficiency Hypoglycemia Blood glucose level IV dextrose Hypothermia Tamponade (cardiac) Check temperature (unlikely with witnessed arrest and short outside time) Muffled heart tones (impossible to detect in pulseless state) Warm IV fluid boluses to maximize preload Tension Pneumothorax Check bilateral breath sounds Pleural decompression of affected side 95

96 Outcome / Disposition Patient already in ambulance Electrical activity ceases now in asystole No response to 3 rounds of epinephrine and high quality CPR What do you do? Transport to hospital? Medical Control! 96