Hold That Epi!

   The patient is surprised by the news but understands the explanation. She volunteers that people in her family have had heart problems, but they all had chest pain. She continues to deny having that.

   As the crew puts her on the monitor and oxygen and she swallows the aspirin, the paramedic calls the ED with a report. They move to the medic for transport to a hospital with a cardiac intervention unit. En route, the patient says her sore throat is gone.

Hospital Management

   The ED is prepared by the time the patient arrives. Her initial EKG is reviewed again by the paramedic and the emergency physician, and another is performed. The EKG done in the ED is completely normal. The physician examines the patient, who again reports no chest discomfort, diaphoresis or shortness of breath. The EMS EKG is shown to the cardiologist, who orders preparations for the patient to go to the cardiac intervention unit for catheterization. Although she is completely symptom-free in the ED, with a normal EKG, her acute symptoms and the abnormal EKG obtained by the paramedic indicate a high-risk patient. The catheterization is performed 30 minutes after arrival, and the patient is found to have two critical coronary artery lesions, one of which had clearly caused her symptoms. Both are opened, and stents placed. The patient is released the next day. She and the cardiologist both send notes of gratitude to the Attack One crew for suspecting something beyond the initial complaint, and identifying an acute coronary syndrome.

Case Discussion

   This incident demonstrates the wide net that is cast in evaluating patients for acute myocardial infarction. Emergency providers, both prehospital and in the emergency department, have noted a changing presentation of acute coronary syndromes (ACS), which include acute MI. The term is now used globally to refer to symptoms beyond just chest pain. The American Heart Association has initiated an educational program that teaches patients about the range of symptoms that may represent a sudden or worsening heart problem. EMS providers should be knowledgeable about the expanded nature of presenting complaints that may indicate cardiac ischemia.

   Acute coronary syndrome is an umbrella term used to describe a group of clinical symptoms compatible with acute myocardial ischemia due to insufficient blood supply to the heart muscle. This usually results from coronary artery disease. Patients who have symptoms of ACS or are suspected of having acute myocardial ischemia should have 12-lead EKGs performed, which may or may not show ST segment elevation. Patients who have discomfort (particularly with exertion) without ST segment elevation may have unstable angina. Thus ACS refers to the spectrum of clinical conditions ranging from unstable angina to acute ST segment-elevation myocardial infarction (STEMI).

   It is likely that most ACS cases now present with symptoms that do not include chest pain. These may include:

• Discomfort in the upper body, from groin to jaw. The patient may describe uncomfortable pressure, squeezing, fullness or pain, and it may be directly related to exertion. The discomfort can occur in either arm, the back, neck, jaw or abdomen;
• Shortness of breath not typical for the patient;
• Diaphoresis;
• Syncope or light-headedness;
• Sudden-onset nausea or vomiting;
• Palpitations.

   Physical evaluation of a potential ACS patient will focus on the cardiovascular system, to include blood pressure, pulse rate and regularity, evidence of respiratory distress, and indicators of overall perfusion. A very important symptom to ask for and physical finding to examine for is diaphoresis. Diaphoresis indicates a sudden release of catecholamines from the adrenal glands, and is a consistent finding in patients having hypoglycemic insulin reactions or acute coronary syndromes. As in this case, it may be the only physical finding that indicates an ACS condition.