2-9 ADULT CHEST PAIN

Life threatening etiologies for chest pain, such as acute MI, aortic dissection, pulmonary embolism and others, should be considered in all patients with a complaint of chest pain regardless of age. If the etiology is unclear, the provider should consult Medical Control and err on the side of cardiac treatment.

EMR - Emergency Medical Responder

1. Perform initial assessment to include:
2. Time of onset of symptoms or change in symptoms
3. Past Medical History of cardiac disease, diabetes or hypertension
4. Any interventions performed (previous medications, aspirin, nitroglycerin, etc)
5. Administer Oxygen at appropriate flow rate
6. Focused physical exam for cardiac patient, including baseline vital signs
7. Call for ALS intercept.
8. Prepare for transport

EMT - Emergency Medical Technician  Perform/Confirm All Above Interventions

1. If suspected cardiac etiology:
2. Assure ALS intercept is en route and initiate transport as early as possible, especially if the patient is:
   1. Hypotensive
   2. Has unrelieved pain
   3. Has a heart rate > 140 or < 50
   4. Nitroglycerin is administered
3. Apply cardiac monitor using monitoring electrodes if trained to do so.
   1. Perform 12 lead EKG if trained to do so. Read the computer interpretation and if “Acute Myocardial Infarction” notify Medical Control of computer reading.
4. Evaluate for aspirin use:
   1. Contraindications:
      1. Inability to swallow
      2. Allergy to aspirin or other anti-inflammatory
      3. Active GI Bleeding
      4. Patient has already taken 160 mg or more of ASA in the last 4 hours
5. Administer four 81 mg tablets of chewable aspirin.
6. Evaluate for assisting the patient in taking their own nitroglycerin:
   1. Contraindications:
      1. Hypotension (SBP < 100 mm Hg)
      2. Head injury
      3. Recent use of erectile dysfunction drugs, such as Viagra
      4. Patient has already taken 3 of their own nitroglycerin
   2. Consult Medical Control for authorization to assist the patient with taking their own nitroglycerin, up to 3 doses.
      1. Place or spray under tongue
      2. Reassess vital signs for hypotension after each intervention and if the SBP remains above 100 mm Hg, may repeat every 3-5 minutes to a total of 3 doses.
7. Initiate transport, with close observation.
8. If cardiac etiology is not suspected consult Medical Control for further orders and begin transport.

AEMT – Advanced Emergency Medicine Tech   Perform/Confirm All Above Interventions

1. Perform 12 lead EKG on all patients with a suspected cardiac etiology for their pain. If the computer reading is an Acute MI, immediately consult Medical Control to notify them of a “Code STEMI” and treat via ST Elevation MI protocol.
2. Establish IV access
3. Administer nitroglycerin
   1. Unless any of the following are true: (If true, do not administer nitroglycerin):
      1. This is an inferior or posterior STEMI
      2. SBP < 100 mmHg
      3. Patient has already received 3 doses of NTG
      4. Patient has recently taken erectile dysfunction drugs such as Viagra, Cialis, or Levitra.
   2. Place or spray under tongue
   3. Reassess vital signs for hypotension after each intervention and if the SBP remains above 100 mm Hg, may repeat every 3-5 minutes to a total of 3 doses.

Intermediate - Perform/Confirm All Above Interventions

1. Perform / Evaluate 12 lead EKG. If suggestive of ST Elevation MI, treat per STEMI protocol.
   1. If presumed cardiac etiology:
   2. Evaluate rhythm strip and treat any identified dysrhythmia via appropriate ACLS protocol.
2. Administer fentanyl (Sublimaze) 50 mcg IV/IO if patient has continued pain despite nitroglycerin and aspirin.
   1. Reassess vital signs after each dose.
   2. May repeat every 3- 5 minutes to a total dose of 150 mcg of fentanyl (Sublimaze) provided SBP remains above 100 mm Hg before each dose.
3. If cardiac etiology is not suspected begin transport and consult Medical Control for further orders.

Paramedic - Perform/Confirm All Above Interventions

1. Confirm above.