Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Chest Pain Refusals

Further thoughts on EMS case law? AMA Refusals, Death, and Documentation – Life Under the Lights.

How do we determine what is low risk chest pain?

One of the most common judgment calls in the emergency department (ED) is also one of the thorniest: deciding whether to send home a patient who is complaining of chest pain but is highly unlikely to have heart disease. The person is an adult younger than 40 years and with no family history of cardiac problems, and both the ECG and blood test results for troponin are clear.[1]

Under 40? How old was the patient in the article referenced by Ckemtp?

I didn’t see an age.

The article I quoted above, cites this position statement (below) from the AHA. You know the American Heart Association, the people who write the guidelines we use as the basis for EMS cardiac protocols.

Assuming that this is a low-risk chest pain patient, what does the AHA consider to be the defensible way to approach this patient?

A high degree of suspicion and recognition of atypical presentations is important, because a significant number of patients present with “anginal equivalents” rather than chest pain. These symptoms include jaw, neck, or arm discomfort; dyspnea; nausea; vomiting; diaphoresis; and unexplained fatigue. These are seen more frequently in the elderly, women, and diabetic patients. Sharp, stabbing, or reproducible pain reduces but does not exclude the likelihood of ACS. Pleuritic chest pain is consistent with a pulmonary condition, musculoskeletal disease, or pericarditis. However, the Multicenter Chest Pain Study found that 22% of patients presenting with symptoms described as sharp or stabbing pain (13% with pleuritic pain and 7% with pain reproduced on palpation) were eventually diagnosed with ACS. 11 The National Heart Attack Alert Program recommends that patients with any of the aforementioned presenting symptoms should be assessed immediately and referred for rapid evaluation. 25 [2]

Jaw, neck, or arm discomfort; dyspnea; nausea; vomiting; diaphoresis; unexplained fatigue, and other symptoms.

These are seen more frequently in the elderly, women, and diabetic patients.

Perhaps this description of chest pain is more accurate –

Not the typical non-diabetic middle-aged man chest pain.

Why do we feel that we should assess every possible cardiac patient as if that patient is a non-diabetic middle-aged man?

When assessing female patients, do we not understand that they are not non-diabetic middle-aged men?

When assessing young men, do we not understand that they are not non-diabetic middle-aged men?

When assessing diabetic patients, do we not understand that they are not non-diabetic middle-aged men?

When assessing old men, do we not understand that they are not non-diabetic middle-aged men?

Physical Examination
The physical examination, although more specific than sensitive, can be useful to identify higher-risk patients. Signs of heart failure reflect left or right ventricular dysfunction. Bruits usually indicate peripheral arterial disease and increase the risk of concomitant CAD. The examination should also target potential noncardiac causes for the patient’s symptoms, such as unequal extremity pulses (aortic dissection), prominent murmurs (endocarditis), friction rub (pericarditis), fever and abnormal lung sounds (pneumonia), or reproduction of chest pain with palpation of the chest wall (musculoskeletal disorders). A normal physical examination is present in the majority of uncomplicated cases of ACS and contributes to the initial impression of low clinical risk.
[2]

A normal physical examination is present in the majority of uncomplicated cases of ACS and contributes to the initial impression of low clinical risk.

Why do we lie to ourselves about chest pain?

EMS is not responding to 911 calls to look for reasons that the patient’s symptoms are not cardiac.

Footnotes:

[1] The Perils of Low-Risk Chest Pain: Emergency Physicians Struggle to Balance Risk With Overtesting
Jan Greene
Annals of Emergency Medicine
Volume 56, Issue 4 , Pages A25-A28, October 2010
Free Full Text from Annals of Emergency Medicine

[2] Testing of Low-Risk Patients Presenting to the Emergency Department With Chest Pain. A Scientific Statement From the American Heart Association.
Amsterdam EA, Kirk JD, Bluemke DA, Diercks D, Farkouh ME, Garvey JL, Kontos MC, McCord J, Miller TD, Morise A, Newby LK, Ruberg FL, Scordo KA, Thompson PD; on behalf of the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology, Council on Cardiovascular Nursing, and Interdisciplinary Council on Quality of Care and Outcomes Research.
Circulation. 2010 Jul 26. [Epub ahead of print]
PMID: 20660809 [PubMed – as supplied by publisher]

Free Full Text PDF – Only Available as a PDF

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