Chest pain, emergency patient management
Chest pain, or chest discomfort, is the fourth most common emergency that EMS professionals respond to, accounting for about 10% of all EMS calls
Causes of chest pain can vary from minor problems, such as indigestion or stress, to serious life-threatening emergencies, such as heart attack or pulmonary embolism
When treating their patients, medical first responders will often pay close attention to how the chest pain is described to better understand the severity of the emergency.
For most people, chest pain may present itself as a “stabbing,” “burning,” “aching,” “sharp,” or “pressure-like” sensation.
Chest pain may also radiate, or move, to other areas of the body, including the neck, arms, spine, back and upper abdomen.
Other symptoms associated with chest pain can include nausea, vomiting, dizziness, shortness of breath, anxiety, and sweating.
The type, severity, duration, and associated symptoms of chest pain can help guide the diagnosis and treatment of this medical emergency.
Diagnosing the cause of chest pain is challenging and requires an understanding of the possible causes, a careful physical examination, patient medical history, and attention to detail.
What Is Chest Pain?
Chest pain is pain or discomfort in the chest.
The pain typically occurs in the front of the chest, and may be described as a sharp or dull pressure, heaviness, or squeezing.
Associated symptoms may include pain in the shoulder, arm, upper abdomen, or jaw, along with nausea, sweating, or shortness of breath.
Causes of Chest Pain
Chest pain falls into one of two categories, heart-related pain or non-heart-related pain.
Under the category of heart-related pain, there is also a type of pain called angina (also known as angina pectoris), which is caused by a lack of blood flowing to the heart.
Serious and relatively common causes of chest pain may include any of the following conditions:
- Acute coronary syndrome, such as a heart attack (31%)
- Gastroesophageal reflux disease (30%)
- Muscle or skeletal pain (28%)
- Pneumonia (2%)
- Pulmonary embolism (2%)
- Pneumothorax or pericarditis (4%)
- Aortic dissection (1%)
- Shingles (0.5%)
- Other common causes include esophageal rupture and anxiety disorders. Determining the cause of chest pain is based on a person’s medical history, a physical exam, and other medical tests.
Management of chest pain is based on the underlying cause.
Initial treatment often includes medications, like aspirin and nitroglycerin.
When the cause is unclear, however, the person will be transported to a nearby hospital or medical facility for further evaluation.
In children, the most common causes for chest pain include:
- Musculoskeletal (76–89%)
- Exercise-induced asthma (4–12%)
- Gastrointestinal illness (8%)
- Psychogenic causes (4%)
- Chest pain in children can also have congenital causes.
When to Call Emergency Number for Chest Pain
If you suspect that you are having a heart attack, immediately call Emergency Number or go to your nearest hospital or emergency clinic.
If you have unexplained chest pain lasting more than a few minutes, seek emergency medical help right away rather than trying to diagnose the cause yourself.
How to Treat Chest Pain
Some causes of chest pain are life-threatening, such as heart attack or pulmonary embolism.
For this reason, if you have unexplained chest pain lasting more than a few minutes, you should seek emergency medical help immediately.
Call Emergency Number. Do not try to ignore or wait out the symptoms, because it could be an indication of a heart attack or other serious medical condition.
Call Emergency Number, and if EMS services are not available have someone drive you to the nearest hospital.
You should only drive yourself to a medical facility as a last resort.
Doing so can put you or others at risk if your condition suddenly worsens.
Chew an aspirin. Chewing 2 tablets of aspirin (150 mg) may reduce the risk of death by as much as 24% if taken in the early stages of a heart attack.
Do not take aspirin if you are allergic, have problems with bleeding, or if you take other blood-thinning medications.
Most importantly, avoid taking aspirin if your doctor has instructed you to avoid it for any reason.
Take nitroglycerin, if prescribed. If you think you’re having a heart attack and your doctor has prescribed nitroglycerin for you, take it as directed.
Nitroglycerin can be ingested either as a tablet (under the tongue) or via a transdermal patch over the chest.
Nitroglycerin can reduce the chest pain and improve the blood supply to the heart.
Begin CPR, if directed. If a suspected heart attack victim is unconscious, call Emergency Number and an EMS dispatcher may advise you to begin cardiopulmonary resuscitation (CPR).
If you haven’t received CPR training, medical experts recommend performing only chest compressions (about 100 to 120 per minute).
Use an automated external defibrillator (AED), if available.
If the heart attack victim is unconscious, and an AED is immediately available, follow the device instructions and use it.
How Do EMTs & Paramedics Treat Chest Pain
For all clinical emergencies, the first step is rapid and systematic assessment of the patient. For this assessment, most EMS providers will use the ABCDE approach.
The ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach is applicable in all clinical emergencies for immediate assessment and treatment. It can be used in the street with or without any equipment.
It can also be used in a more advanced form where emergency medical services are available, including emergency rooms, hospitals or intensive care units.
Treatment Guidelines & Resources for Medical First Responders
Treatment guidelines for chest pain with heart attack can be found on page 27 of the National Model EMS Clinical Guidelines by the National Association of State EMT Officials (NASEMSO).
These guidelines are maintained by NASEMSO to facilitate the creation of state and local EMS system clinical guidelines, protocols, and operating procedures.
These guidelines are either evidence-based or consensus-based and have been formatted for use by EMS professionals.
The guidelines include a rapid assessment of the patient for symptoms of chest pain, which may include:
- Shortness of breath
- Abnormal respiratory rate or effort
- Use of accessory muscles
- Quality of air exchange, including depth and equality of breath sounds
- Wheezing, rhonchi, rales, or stridor
- Cough
- Abnormal color (cyanosis or pallor)
- Abnormal mental status
- Evidence of hypoxemia
- Signs of a difficult airway
Pre-hospital treatments and interventions might include:
- Non-invasive ventilation techniques
- Oropharyngeal airways (OPA) and nasopharyngeal airways (NPA)
- Supraglottic airways (SGA) ort extraglottic devices (EGD)
- Endotracheal intubation
- Post-intubation management
- Gastric decompression
- Cricothyroidotomy
- Transport to closest hospital for airway stabilization
EMS providers should reference the CDC Field Triage Guidelines for decisions regarding transport destination for injured patients.
EMS Protocol for Atraumatic Chest Pain
Protocols for pre-hospital treatment of chest pain and discomfort vary by EMS provider and can also depend on the patient’s symptoms or medical history.
If the cause of chest pain is atraumatic, a typical protocol might follow these initial steps:
- Conduct scene size up, primary assessment, and immediate life-saving interventions. Have an AED nearby and ready.
- In patients exhibiting shortness of breath or hypoxia (SPO2 < 94%), administer oxygen to improve respiratory symptoms or saturation (94–99%).
- Avoid exerting the patient (i.e., if possible, patient should be carried) and place in a position of comfort unless necessitated by other factors.
- Request Advanced Life Support (ALS) considering their availability and hospital proximity. Consider transport to a receiving facility with emergency cardiac catheterization (PCI) capability. Minimize on scene time.
- Obtain baseline vital signs, history, and conduct a secondary assessment attentive to contraindications to fibrinolytic therapy (recent bleeding, surgery, etc.) and cardiac compromise.
Initiate treatment of oral aspirin and sublingual nitroglycerin or glyceryl trinitrate. Prompt transport is important — DO NOT delay transport to administer these treatments.
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