Paramedics Assessment of Ischemic Chest Pain - Essay Example

?ODER No: 522262 PARAMEDICS’ ASSESSMENT OF ISCHEMIC CHEST PAIN A CASE STUDY INTRODUCTION The assignment will consist of the following A brief description of Ischemic Chest Pain, its causes and symptoms, and its early treatment [2] A case study of such a condition and the paramedic’s assessment [3] Assessment essay – in which one significant finding from the patient assessment is discussed 1. Ischemic Chest pain Ischemic is the term applied to a restriction of the blood supply to the heart muscle, and it generally manifests itself by the appearance of a severe, sometimes excruciating pain arising from decreased blood flow through the coronar y artery (Mosby, 2009). However, it should be realized that this is not the sole cause of chest pain, and that it may be due to “classical angina” (Devonshire Lodge Practice, 2011) whose symptoms generally appear during, or immediately after exercise and subside after resting. However, it must also be said that where someone complains of “discomfort across the center of the chest coming on during exercise that stops on rest and then GTN [glycerine trinitride] tablets relieve the pain within 5 minutes he/she is going to have ischemic heart disease almost without doubt” (Devonshire Lodge Practice, 2011). As will be discussed later, the development of ischemic chest pain is due to many causes, and so it is appropriate to consider the symptoms of the disease (Ischemic Heart Disease, 2009), which include the following- Chest pain Exertional dyspnoea – breathlessness during or following exertion Orthopnoea – difficulty sleeping [breathlessness] without several pillows Cardiomegaly – enlargement of the heart, either disease related or congenital Peripheral oedema – a build-up of body fluids in the body’s extremities Cardiac arrhythmias – irregular or abnormal heart rhythms Paroxysmal – a temporary attack; convulsion or spasm Although the immediate treatment by the paramedics is of paramount importance and, if carried out effectively followed by early delivery to the hospital, is able to prevent further complications, the early treatment on arrival at the hospital is also vital, especially the ability to distinguish between those patients who were at low- [or zero-] risk and high-risk patients needing immediate life-saving intervention (Vannan & Narula, 2005). It is hoped that the task will be made easier by paramedic assessment, which should be thorough enough to eliminate many uncertainiies. That is why a systematic stepwise series of protocols such as those advocated by Domanovits et al. (2002) and Anderson (2002) is essential. 2. Case History of paramedic’s assessment of ischemic chest pain Complete History & Assessment of Patient Presenting Complaint Chest Pain Allergies None Communicable Diseases None PHx- Past History O/A – On Arrival O/E – On Examination Med’n- Medication Patient’s Name: William Templeton: Age 57 Address: 12 Andover Terrace, STAINES Bucks. SL4 3TR O/A - Emergency services called by patient’s family at 0956 hrs, arrived at patient’s home 1015 hrs..William, a white male, complained of severe chest pain, breathlessness, nausea and dizziness. He also appeared pale and slightly sweaty. PHx – Patient was normally in good health, a non-smoker, moderate drinker and ate healthy meals at home. He also took regular exercise. His grandfather had been gassed in WWI and his grandmother had suffered intermittent asthma attacks in her later years. As to childhood illnesses, William reported German measles, two bouts of chicken pox, and tuberculosis at the age of 6, which had affected stomach and neck glands and also the lungs. Chicken pox and TB raised alarm signals since the former could have returned as shingles (pain comes some time before the rash, and lung damage may have contributed to ischemic heart disease. O/E – The assessment procedures followed the guidelines established by the York Region Base Hospital Program (Anderson, 2002). For clarity and consistency during patient questioning the following mnemonic was used: PQRST [Provokes; Quality; Region/Radiation; Severity; Time/Onset/Duration Patient Questioning Provokes – Why did this happen? William said that he was standing in the living room and yremembered that he had left his wallet upstairs; while running up the stairs he suddenly felt breathless and dizzy. He managed to get downstairs again, began to feel distinctly unwell, and was conscious of a severe chest pain. When he sat quietly the pain became slightly less severe, but it returned again when he moved or tried to breathe more deeply. Quality – Describe how it feels? To avoid suggesting possible answers, William was asked to describe his symptoms in his own words. It seemed that he experienced a combination of sensations and emotions, which included anxiety, sweating and slight pain in the region of the neck and shoulder, some nausea and a feeling of distension in the area above the stomach. He also said that the initial tiredness and dizzy feeling had not entirely subsided. Region/Radiation – Where is the pain and does it move about or remain static? William said that while the most severe pain symptoms began in the middle of the chest and remained there, there were also sensations of pain around the neck and jaw regions, and later in the upper left arm and shoulder. Severity – How bad is it? As not all people feel pain in the same way or to the same level, William was asked to classify the intensity of the pain on a scale of ten, with 1 signifying no sensation of pain and 10 equal to the highest pain intensity he had ever experienced. William admitted that he had not experienced this type of pain before, and said that at its sharpest it would be 8, diminishing to 4 or less as time went on rovided he did not exert himself. Time/Onset/Duration – When did it start and how long did it last,is it still there? Experience has shown that this type of question is difficult to quantify. William said that as far as he could remember he first felt the most extreme discomfort at about 0930 hrs. This was consistent with the records which reported that the emergency services had received the call at 0956 hrs, and he had arrived at William’s home at 1015 hrs. The time this question was asked was 1040 hrs. The pain was now relatively slight provided the patient remained seated and did not exert himself. He said that before the pain he had been feeling somewhat tired and overworked for some days as he was in the middle of an important assignment at work. The sensations of breathlessness, dizziness and severe chest pain developed quite rapidly after he had run upstairs. Examination of the airways and chest assessment The sequence of protocols is of primary importance, and its purpose is “to ensure that the patient has, and is able to maintain, an adequate airflow down to the level of the larynx” (Anderson, 2002). They comprise three basic evaluations: Look [inspect], Listen [auscultate], Feel [palpate]. The sequence of the three stages, and their relevance, was explained to the patient together with the particular features which were to be carried out. These were: [a] Examination of the neck and thorax [b] Adequacy of ventilation [c] Adequacy of oxygenation ( i.e. cyanosis, level of awareness etc.) [d] Most important – status of the whole patient. Since William was fully conscious, there was no need to take measures to ensure the airway remained unblocked and that the tongue did not obstruct the passage. It was also found acceptable to carry out the examination with the patient seated in an upright chair. He was then asked to remove his shirt and vest to make the assessment easier to carry out. Look William was fully conscious at all times, although he appeared to be rather easily fatigued. He showed no obvious signs of distress, and his breathinh seemed normal – apart from feeling slight residual pain – although he still seemed rather pale and sweaty. His appearance appeared to satisfy all the usual signs of a person suffering from ischemic chest pain of a transient nature. There were no signs of nail bed and mucous membrane discoloration, and no examples of asymmetry in the inspiration and expiration sequences. Listen Auscultation followed a systematic pattern in order to avoid missing any areas which might contain valuable information. It was carried out on William’s back since there is less likelihood of sounds being dissipated by intervening bone and muscle. Also, since many of the sounds heard during respiration occur towards the end of the cycle, it was important that several full inspiratory and expiratory cycles were performed during the examination. As an additional precaution, William was asked to give deep breaths through the mouth rather than through the nose, since this eliminates airway sounds during auscultation. Sounds. William was asked to sit on a stool with arms crossed in front of the chest so as to make access to the lung area easier. The procedure was`then carried out with a stethoscope from bottom to top and from side to side. The auscultation procedure was intended to discover and confirm the following:- The presence or absence of breath sounds The equality of sounds between corresponding areas The presence of abnormal additional sounds and the sounds heard during the examination are basically of two types:- Normal (vesicular) breath sounds Abnormal (adventitious) sounds The findings in the two categories can be summarized as follows. The vesicular breath sounds generally appeared to be normal except for the superposition of some adventitious sounds, which will be discussed later. The vesicular breath sounds were comparatively soft and pitched at a low level, and exhibited a gentle rustle, and the bronchovesicular and bronchial sounds were at the intensity and cycle time to be expected. Of the adventitious sounds heard during auscultation were slight wheezes - which can be described as relatively high pitched and possibly due to the movement of air through diminished terminal airways, probably as a result of his grandmother’s predisposition to asthma attacks – revealed by the family’s medical history. The wheezes were not accompanied by any excess mucous production. Another adventitious sound was the presence of a series of crackling sounds during inspiration and expiration. The most accurate description would be residual damage to the lungs resulting from childhood tuberculosis. Feel Following auscultation, the airways and chest assessment protocol was completed by palpation, manly to discover whether or not William had suffered any injuries which had not been apparent on inspection. Firm pressure was applied on the lateral rib cage followed by downward pressure on the sternum. This had to be doen with caution in order to lessen the possibility of any undetected damage to individual ribs. None appeared to have been present.. The procedure was also followed by palpating the clavicles, but no damage was detected. Patient’s medical history By careful and considerate questioning of the patient and those family members who were present, it was discovered the William was a non-smoker, and had been all his life, was a moderate drinker – the occasional glass of wine over a month, and usually half a pint of lager on Saturdays. He had no experience of drug abuse and believed that he ate reasonably healthy meals as his wife was a good health-conscious cook. Due to the demands of his occupation as a surveyor however, he was often at work on building sites at lunchtimes and had to resort to snacks or sandwiches. He was quite athletic and enjoyed golf and tennis whenever he could find time to indulge himself. His grandfather was gassed during World War I and, as mentioned earler, his grandmother had suffered intermittent asthma attacks in her later years. William himself did not appear to attach any particular significance to these issues. He said that, apart from the usual childhood illnesses including two bouts of chicken pox – one at about 8 years old, and the other when he was 19 – he had suffered with tuberculosis at the age of 6, and the disease had affected the glands in his neck and stomach and his lungs. After a period of convalescence lasting several years he appeared to have made a full recovery. Two of the occurrences in William’s medical history raised questions and could have a bearing on his present condition: Tuberculosis – which probably contributed to the adventitious sounds in the lungs The two incidences of chicken pox, particularly the latter, since the chicken pox virus is known to be capable of lying dormant for some years after the initial infection, and emerging later to cause the infection known as shingles. Although shingles.is usually accompanied by a rash, this generally appears a little while after the pain, and so may not have appeared yet. Medication William confirmed that he had for some years suffered from hypertension, and raised cholesterol levels; both conditions being controlled by beta-blockers [Propanolol] and statins [Lipitor] respectively. While the former are valuable in controlling the hypertension, they do have an effect on the heart and blood vessels and may mask an existing heart condition. He also confirmed that he had taken a propanolol tablet that morning in order to reduce the effects of hypertension. Additional Information During the journey on the way to hospital, William began to look increasingly uncomfortable, and complained that his legs had begun to feel painful. When the blanket which covered his body was lifted it was observed that there was a slight swelling and reddening in both ankles. The patient was asked if this had happened before and if he could say what had caused it. William, after some time, said that he did remember that while on a family holiday in the Red Sea region of Eilat about five years ago, he had been snorkelling off the beach and had accidentally trodden on the spikes of some coral or shellfish – he could not remember which – and the injury had caused him some considerable pain and swelling around the soles of the feet and ankles, and had taken some weeks to subside completely. This effect was noted. Medication administered by paramedics In view of the shortness of the journey to hospital – 20 minutes – together with the patient’s comparative lack of distress and the fact that he had already taken propanolol that morning, it was not felt necessary for any additional thrombolytic agents such as aspirin or glycerine trinitrate to be administered before admission. Conclusion On the evidence shown after a thorough assessment it appeared that the patient had suffered a transient ischemic chest pain which, although severe, was not felt to be life-threatening. There were several factors which should be taken into consideration when deciding how to treat the parient: Early onset and treatment of tuberculosis Two attacks of chicken pox – one in childhood, the second as an adult A foot infection sustained while swimming in possibly infected waters of the Red Sea 3. ASSESSMENT ESSAY Assessment Essay During the patient assessment case study one factor emerged as significant: the patient’s early history of tuberculosis and its probable connection with the adventitious crackles heard during the auscultation procedure. It is appropriate, therefore, to consider the fundamentals of the disease, how it manifests itself, how it may be treated, detection by paramedic chest assessment and, finally whether or not there are any indications for changes to the assessment protocols. Tuberculosis explained Tuberculosis, has been known since earliest times and due to the wasting effect on the patient was termed “consumption” . In 1882 the cause was found to be the tubercle bacillus Mycobacterium tuberculosis (Marcovitch, 2005). Although the means by which the infection acquired is generally by inhalation – thus the most common site is in the lungs – ingestion is also a possible route through contaminated milk, and therefore sites such as the lymph glands and other areas within the body may harbor the infection. Although the disease showed a significant decline during the major part of the 20th century – mainly due to improved social conditions and diet - there has been a slow but steady increase since the 1980s, partly due to increased immigration from areas with high incidence of the condition. The pathology of the condition “Once the bacteria are inhaled, they are engulfed by macrophages...in the alveoli...[and] replicate within the macrophages for 2 to 3 weeks before spreading throughout the body (Swierzewski, 2000). While the macrophages are able temporarily to prevent the spread of the bacteria, it is possible for them to remain dormant for a long period before becoming reactivated. CT scans have been found to show “centrilobular nodules and branching linear structures...lobular consolidation, cavitation and bronchial wall thickening ...enlargement of the lymph nodes” (Lee, J. Y. et al., 2000; Furqan & Butler, 2010). Detection during chest assessment by paramedics The most obvious signs are the appearance of crackles in the area of the upper lung, coughing and blood in the sputum, and also in the general appearance of the patient which may include palor, obvious weight loss, breathlessness and night sweats (Swierszewski, 2000). Analysis of the crackles showed that the transmission of crackles is strongly directional and the waveforms manifest themselves in two forms: “starting segments” and “decay segments” (Mori, M. et al., 1980) Indications for changes in assessment protocols Whereas the detection of crackles in the lung region has been accepted as a primary indication of lung disease Carbone et al. (2004) have found that in a survey of 108 patients with Interstitial Lung Disease, none of those presenting with Tuberculosis had crackles, but more than half showed the presence of dry coughs. Although no changes are recommended, it is suggested that, in the light of the above findings paramedics should be on the alert for the appearance of tuberculosis , Reference List Carbone, R. G. et al., 2004. Value of cough and or/crackles in differential diagnosis of interstitial lung disease. American College of Chest Physicians [online] Available at http://meeting.chestpubs.org/cgi/.../755S [Accessed 30 April 2011]. Furqan, M. & Butler, J, 2010. Miliary Pattern on Chest Radiography: TB or not TB? Mayo Foundation for Medical Education and Research [online] Available at http://mayoclinicproceedings.com/.../108.full [Accessed 30 April 2011]. Lee, J.Y. et al., 2000. Pulmonary tuberculosis: CT and pathological correlation. Journal of Computer Assisted Tomography. 24 (5). 691-698. Marcovitch, H., 2005, Tuberculosis, Black’s Medical Dictionary (41st Edn). Mori, M.et al., 1980. Waveform and spectral analysis of crackles, Thorax, 35 (11). 843-850. Swierzewski, S. J., 2000. Signs & Symptoms of Tuberculosis. Cornell University [online] Available at http://pulmonologychannel.com/.../symptoms... [ Accessed 30 April 2011]. Swierzewski, S. J., 2000. Tuberculosis (TB) Pathology. Cornell University [online] Available at http://pulmomologychannel.com/.../pathology... [Accessed 30 April 2011]... REFERENCES Anderson, J. (Ed), 2002. Advanced Chest Assessment, York Region Base Hospital Program, 1-18. The Devonshire Lodge Practice, 2011. Chest Pain [online] Available at http://www.devonshirelodge.co,uk/acute/chestpain.htm [Accessed 19 April 2011] Domanovits, H. et al., 2002. Acute chest pain – a stepwise apporoach, the challenge of the correct clinical diagnosis. Resuscitation, 55, 9-16. Ischemic Heart Disease, 2009, Symptoms and Treatment [online] Available at http://www.ischemicheartdisease.co.uk/ [Accessed 19 April 2011]. Mosby, 2009, Mosby’s Medical Dictionary, (8th Edn.). Elsevier. Available at http://medical-dictionary.thefreedictionary.com/ischemiv+pan [Accessed19 April 2011]. Vannan, M. A. & Narula, J., 2005. Ischemic Versus Nonischemic Chest Pain in the Emergency Room. Journal of the American College of Cardiology, Vol. 46 (5), 928-929. Read More