There are several things to keep in mind in evaluating the patient whose presenting complaint is chest pain, but in the prehospital setting, your primary focus is rapid determination of the likelihood that the patient is having a life threatening condition such as an Acute Myocardial Infarction (AMI), a pulmonary embolism (PE), or acute aortic dissection (AAD) and is in need of rapid transport.
Having a structured and systematic approach to these cases will help you develop and streamline the diagnostic workup and more quickly determine transport priority. Chest pain must always be considered both serious, and cardiac in nature until proven otherwise. You should not hesitate to start high flow oxygen therapy before completing your assessment.
Signs and Symptoms[edit | edit source]
OPQRST is a mnemonic acronym used by many medical professionals during the Signs and Symptoms step of the SAMPLE history to elicit the time course, severity and quality of a patient's pain to help with the differential diagnosis.
|Mnemonic component||Questions to ask||Findings|
|O||Onset||"What were you doing when it started?"||Pain brought on by exertion that subsides is more characteristic of angina, whereas gradually increasing pain should increase your suspicion of an AMI. Abrupt onset of maximal pain is highly suspicious of an AAD|
|P||Provocation or Palliation||"Does anything make it worse? Anything makes it better?"||Repositioning a patient or resting does not tend to help chest pain caused by an AMI, PE or AAD. If repositioning or rest helps alleviate the pain, it may be from another source. Chest pain that is worse with breathing is suspicious for a PE|
|Q||Quality of pain||"Can you describe it to me? Is it sharp, dull, constant, intermittent?"||For cardiac involvement, in addition to pain, often patients will describe it as a pressure, discomfort, or tightness. Not all AMIs present with the classic "substernal chest pain". "Tearing" pains are more common in AD|
|R||Region and Radiation||"Where exactly does it hurt? Does the pain extend anywhere else?"||Myocardial infarction and Angina can both produce pain that radiates to the arms and jaw. In women the pain can often feel like indigestion. Any of these could have a cardiac source. Pain in the back or abdomen is more suggestive of AAD|
|S||Severity||"On a scale of 1 to 10, how much does it hurt?"||Low levels of pain to not rule out an AMI or a PE - use the pain scale to help determine whether the pain is getting better or worse. Recheck with the patient after oxygen or nitroglycerin administration.|
|T||Time||"How long has this been going on? How has this progressed over time?"||Angina is typically short lived, and the pain resolves with rest. Pain that does not resolve, or worsens over time should increase your index of suspicion that this is a serious issue requiring immediate transport.|
Medications[edit | edit source]
In the "M" section of SAMPLE (Medications) specifically ask about medications for heart conditions or medications that could induce clotting including
- Birth control pills
Pertinent Medical History[edit | edit source]
In the "P" section of SAMPLE (Pertinent Medical History), ask the patient about both their history of Cardiopulmonary disease as well as risk factors for cardiopulmonary disease including:
- High cholesterol
- Family history
If a PE is suspected, be sure to ask about recent air travel or prolonged sedentary periods, calf swelling/pain or any coagulation irregularities.
Documentation[edit | edit source]
Documentation of medical assessment for chest pain should be included in the Patient Care Report (PCR) in the form:
- "Patient reports 10/10 abdominal pain radiating to her back with no provocation or palliation and an abrupt onset x15 minutes ago. Patient states that pain comes in waves with each heartbeat. Patient describes pain as "tearing"."
- Pertinent medical history should be documented. Example: "Patient has history of HTN and DM with non-compliance with medications. Patient reports that his father and uncle both had several heart attacks early in life. Patient's father had first heart attack at 36 and eventually died from another at 52. Patient is a current smoker smoking 'about half a pack a day'. Patient has not seen a cardiologist in the last several years."
Self Assessment[edit | edit source]
Tips and Tricks[edit | edit source]
- When asking a patient for the Region of pain, ask them to point to the pain. This is useful in several ways. First, it eliminates the potential for miscommunication ("I already told you, I have chest pain). Second, if the patient uses an open hand to indicate the area, their pain is likely localized and not pinpoint. Third, asking the patient to physically demonstrate where the pain is allows for a segue into radiation (ex. "Can you point to where it hurts most? Ok, now does the pain move anywhere? Can you show me?).
- A 1-10 scale can be notoriously inaccurate, but there currently exists no way for a provider to reliably determine a patient's true pain level as pain is subjective and pain tolerance works is also a factor. When using a scale, give definitions of what the endpoints are ("1 is a scratch and 10 is the worst pain you can imagine").
- When asking the patient to describe the quality of the pain (how it feels), try to avoid leading the patient by providing possible answers. Let the patient attempt to answer on their own, if they are unable to easily describe their pain you may provide potential descriptors. Leading the patient with questions like "Does your pain feel like a pressure radiating down your arms?" is problematic in several ways: it removes the patient's agency and may not adequately describe their pain, and it may lead to a patient who has chest pressure that does not radiate answer "no" because their pain does not exactly match the provided answer.
Additional Resources[edit | edit source]
TBD - extra videos to watch, links to other pages for more reading