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All Emergencies - Basic life support principles:
- Maintain an airway
- Assess breathing
- Monitor circulation
Monitor and record all vital signs. |
Chest Pain |
Differential Diagnosis:
- Hyperventilation: highly anxious, light headed, fast respiration
- Angina - Transient chest pain brought on by exertion, emotional upset; relieved by rest & administration of nitrates (Below)
- Myocardial Infarction (Below)
- GERD
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Angina Pectoris:
Angina resolves after 3-8 minutes of rest or after administering nitroglycerin. Shortness of breath may also occur.
Other Signs/Symptoms:
- Transient chest pain brought on by exertion, emotional upset; relieved by rest & administration of nitrates.
- Blood pressure may be normal, elevated or lowered slightly.
- Heart rate usually increases with the possible occurrence of dysrhythmias.
Management of Angina:
If the patient has no history of angina:
- Notify the EMS immediately.
- Terminate dental treatment.
- Administer oxygen
- Administer nitroglycerin tablets or spray in the usual dose.
** Angina pain should be alleviated within 2 minutes with nitroglycerin and should not return.
- Monitor vital signs.
If patient does have a history of angina:
- Discontinue dental treatment.
- Closely monitor circulation.
- Administer nitroglycerin. For patient with history of angina - take their normal dose.
- Dose is typically 1-3 sublingual tablets or 1-3 translingual sprays from the emergency drug kit.
- Nitroglycerin dose may be repeated every 5-15 minutes for a total of 3 doses.
- If pt's nitroglycerin tablets don't alleviate the pain, administer a 2nd dose from of spray from emergency kit.
- Note: Nitroglycerin tablets lose their potency within 8 weeks after bottle is first opened
- If chest pain subsides & does not return, dental treatment may continue.
- Activate EMS if chest pain does not subside, or if pain returns, or if patient advises.
- Administer fibrinolytic (aspirin) unless contraindicated because of GI history.
- Monitor and record vital signs; manage symptomatically until EMS arrives.
After the angina subsides:
- Try to determine the cause of the pain; Modify future treatment as indicated
- Inadequate pain control?
- Severe dental anxiety?
- Urge the patient to get a fresh supply of nitroglycerin immediately.
- Contact the EMS if a patient with history of angina whose pain subsides after administering nitroglycerin, but then subsequently returns.
This is likely not angina, but most likely a myocardial infarction.
MYOCARDIAL INFARCTION:
Signs & Symptoms:
- Almost always precipitated by an acute episode that increases the workload of the heart, including fear, pain or exertion.
- AMI (acute myocardial infarction) lasts longer than angina, is more severe, and does not respond well to nitroglycerin.
- Patient becomes diaphoretic, nauseated and lightheaded. Shortness of breath, generalized weakness, cool moist skin, and cyanosis of mucous membranes. Crushing chest pain.
Management of AMI:
- If the patient has no history of chest pain, or if the chest pain subsides but then subsequently returns, contact EMS.
- Most patients prefer to sit up or semi-upright. If blood pressure drops or consciousness is lost, place patient in supine position with feet elevated slightly.
- AMI patients usually maintain adequate airway & breathe spontaneously.
- Loosen constrictive clothing.
- Monitor & record heart rate & rhythm, and blood pressure.
- Administer oxygen.
- Administer 2 doses of either translingual or sublingual nitroglycerin.
Avoid nitroglycerin if systolic < 90 or if marked bradycardia or marked tachycardia.
- If patient is not allergic to aspirin, have patient chew & swallow a 325 mg. aspirin tablet.
- Traditionally 2-5mg of morphine is administered every 5-15 minutes to manage the pain or administer nitrous oxide (35-65%).
(Nitrous Oxide has been shown to be equal to the analgesic ability of morphine to manage the AMI pain.)
- Continue monitoring vital signs until EMS arrives.
- If patient loses consciousness, place in supine position & reassess and manage the steps of basic life support.
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GERD |
Signs/Symptoms:
Gastro-esophageal reflux disease can closely mimic the symptoms of a heart attack. Symptoms include severe chest pain & heartburn.
Management of chest pain when GERD is suspected:
- Position comfortably - usually upright
- Oxygen if needed
- Get vital signs: Systolic should be at least 100.
- Place patients nitroglycerin 1 tab sublingually (relief in 2-4 minutes if angina is the cause.)
- If no relief in 5 minutes, repeat up to a total of 3 times.
- If no relief, call EMS unless you can connect the etiology directly to GERD.
- Hospital will often be given a GI cocktail of Mylanta, Benadryl 2% and water, which will usually relieve symptoms in 30 minutes.
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