CHEST PAIN/DISCOMFORT

Inclusion Criteria:  Chest pain suspected to be ischemic in nature, even when caused by stimulant toxicity.  This may include classic presentations or anginal equivalents, e.g. epigastric pain/pressure, shoulder, neck or jaw pain/pressure, indigestion, shortness of breath, diaphoresis, or altered mental status.  Acute coronary syndrome (ACS) in diabetic patients, women and the elderly may not present with classic symptoms.  Ischemic chest pain is a very unusual presentation in pediatric patients.  Contact BioTel for all pediatric care under this guideline.

SPECIAL NOTE:  Do NOT administer nitroglycerin to any patient who has taken Viagra® (sildenafil), Levitra® (vardenafil), or Cialis® (tadalafil) within the past 36 hours.

Basic Level

  1. Assess and support ABCs.
  2. Place the patient in position of comfort.  Minimize patient exertion.  If the patient is hypotensive, place him/her supine, and treat according to SHOCK Guidelines.
  3. Administer oxygen, as needed, to maintain a SpO2 of at least 94%.
  4. Administer aspirin 324 mg (4 baby aspirins) OR 325 mg (one adult aspirin) by mouth (chewed before swallowing), regardless of whether patient has taken aspirin prior to EMS arrival.
  5. Begin transport as soon as possible.

Advanced Level

  1. Continuously monitor ECG and ETCO2 (if available) until patient care has been transferred to hospital staff.  Treat arrhythmias under the appropriate guideline. 
  2. Obtain and transmit a 12-Lead ECG. Consult with BioTel, as needed.  Obtain a 12-lead ECG BEFORE giving any nitroglycerin.  NOTE: 3-lead ECG monitoring is not a substitute for a 12-lead ECG.
  3. Establish IV/IO access at a TKO rate or use a saline lock.  Do not delay nitroglycerin administration while attempting to establish vascular access.  However, in patients with ECG evidence suggestive of an inferior wall MI, vascular access MUST be established before administering the first nitroglycerin dose.
  4. 12-lead interpretation: Identify ST-elevation myocardial infarction (STEMI) patients.
    1. Inferior Wall Infarction (ST elevation - leads II, III, aVF) with a systolic blood pressure (SBP):
      1. Less than 90 mmHg:
        1. Position patient flat or with legs elevated.
        2. Administer 20 mL/kg fluid bolus IV/IO.  If SBP remains below 90 mmHg and no pulmonary edema is present, repeat fluid bolus as needed to keep SBP greater than 90 mmHg.  Paramedics may administer up to 1 liter total, cumulative fluid volume under standing orders.
        3. BioTel may authorize the administration of morphine or fentanyl in this patient.
      2. 90 mmHg or greater:
        1. Obtain IV/IO access prior to nitroglycerin administration.
        2. Administer nitroglycerin 0.4 mg SL; may repeat every 5 minutes for a total of 3 doses.  Observe for hypotension.
        3. Morphine 2 mg to 4 mg increments, slow IVP, up to a total maximum cumulative dose of 8 mg for pain unrelieved by 3 doses of nitroglycerin.  Do not administer morphine if SBP falls below 90 mmHg.  NOTE: There is no uniform requirement for all agencies to carry morphine; it is an optional medication; OR
        4. Fentanyl 1 mcg/kg IN or slow IVP.  May repeat every 15 minutes.  Do not exceed 200 mcg as a total cumulative dose.  NOTE: There is no uniform requirement for all agencies to carry fentanyl; it is an optional medication.
    2. Normal ECG and all other infarctions:
      1. Do not delay nitroglycerin administration for vascular access attempts.
      2. Administer nitroglycerin 0.4 mg SL; may repeat every 5 minutes, up to a maximum total of 3 doses, as long as SBP remains above 90 mmHg.
      3. Morphine 2 mg – 4 mg increments, slow IVP, up to a maximum cumulative dose of 8 mg, for pain unrelieved by 3 doses of nitroglycerin, as long as SBP remains above 90 mmHg.  NOTE: There is no uniform requirement for all agencies to carry morphine; it is an optional medication;
      4. Fentanyl 1 mcg/kg via IN or slow IVP.  May repeat every 15 minutes.  Do not exceed 200 mcg total cumulative dose.  NOTE: There is no uniform requirement for all agencies to carry fentanyl; it is an optional medication.
  1. If the systolic blood pressure falls below 90 mmHg in response to nitroglycerin, morphine, or fentanyl:
    1. Position the patient supine or with the legs elevated, if tolerated.
    2. Do not administer additional nitroglycerin or morphine (under standing orders).
    3. Administer a 20 mL/kg Normal Saline bolus IV:
      1. If SBP remains below 90 mmHg and pulmonary edema is not present, repeat fluid bolus as needed to keep SBP greater than 90 mmHg.  Paramedics may administer up to 1-liter total fluid volume under standing orders.
      2. BioTel may authorize the administration of morphine or fentanyl for this patient.
  1. If the chest pain is thought to be stimulant-induced (e.g. cocaine, amphetamine or ecstasy), administer:
    1. Diazepam 2.5 – 5 mg slow IVP/IO/IN/IM; May repeat up to a total, maximum, cumulative dose of 10 mg; OR
    2. Midazolam 2.5 – 5 mg slow IVP/IO/IN/IM; May repeat up to a total, maximum, cumulative dose of 10 mg.
    3. Monitor closely for respiratory depression.
    4. Contact BioTel for authorization for additional dosing.
  2. Monitor the patient’s temperature frequently.  Be prepared to cool the patient aggressively, but do not cause shivering.
  3. Transport patients with a suspected STEMI to a hospital with immediate cardiac catheterization lab capabilities.  You must contact either BioTel or the receiving hospital as soon as possible, so that the cardiac catheterization lab can be activated promptly. When in doubt, consult with BioTel to confirm hospital capability.
  4. For additional patient care considerations not covered under standing orders, consult BioTel.