3. MEDICAL EMERGENCIES

3.5 Chest Pain
3.6 Congestive Heart Failure / Pulmonary Edema


3.5 CHEST PAIN

Chest pain is often the presenting complaint of patients experiencing a myocardial infarction or an ischemic event of other etiology. All chest pain patients should be carefully monitored until a definitive diagnosis can be made at the hospital. All patients with chest pain of a non-traumatic etiology should be considered to be of cardiac origin until proven otherwise.

ASSESSMENT / TREATMENT PRIORITIES

1. Maintain universal blood and body fluid precautions.

2. Maintain an open airway and assist ventilations as needed.

3. Administer oxygen by nasal cannula or mask based upon patient's condition.

4. Obtain appropriate history related to event. Determine time of onset, duration, intensity, character, location, associated symptoms, radiation and/or activities that change (worsen or improve) pain, and patient's activity during onset.

5. Obtain appropriate history related to event, including Past Medical History, Medications, Drug Allergies and Substance Abuse.

6. Monitor ECG and vital signs.

TREATMENT

BASIC PROCEDURES

1. Maintain universal blood and body fluid precautions.

2. Maintain an open airway and assist ventilations as needed.

3. Administer oxygen by nasal cannula or mask based upon patient's condition.

4. Activate ALS intercept, if deemed necessary and if available.

5. Initiate transport as soon as possible with or without ALS.

6. Notify Receiving hospital.

INTERMEDIATE PROCEDURES

1. Maintain universal blood and body fluid precautions.

2. Maintain an open airway and assist ventilations as needed.

3. Administer oxygen by nasal cannula or mask based upon patients condition.

4. Activate Paramedic intercept, if deemed necessary and if available.

5. ALS STANDING ORDERS

a. Provide advanced airway management if indicated (i.e., patient's condition deteriorates).

b. Initiate IV Normal Saline (KVO) enroute to hospital.

6. Initiate transport as soon as possible with or without Paramedics.

7. Notify receiving hospital.

PARAMEDIC PROCEDURES

1. Maintain universal blood and body fluid precautions.

2. Maintain an open airway and assist ventilations as needed.

3. Administer oxygen by nasal cannula or mask based upon patient's condition.

4. Cardiac monitoring / dysrhythmia recognition.

5. ALS STANDING ORDERS:

a. Provide advanced airway management if indicated (patient's condition deteriorates).

b. Initiate IV Normal Saline (KVO). NOTE: A second IV line may be indicated for high risk patient.

c. If a dysrhythmia is identified, treat per protocol.

d. Administer Nitroglycerine 0.4 mg (1/150) SL tablet or spray if BLOOD PRESSURE is greater than 100 systolic; may repeat in 5 minute intervals x two (2) if BLOOD PRESSURE remains greater than 100 systolic (total of 3 doses).

NOTE: If the patient has taken Viagra TM within the last 24 hours, contact medical control prior to administration of Nitroglycerin.

e. If patientís BLOOD PRESSURE drops below 100 systolic: place patient supine and elevate legs and administer a 250 cc bolus of IV Normal Saline.

f. If patient has taken his/her NTG prior to your arrival, and you have determined that the pharmacologic potency of their NTG was normal (based upon standard side effects of NTG, i.e., headache/tingling sensation) without pain relief, contact Medical Control for other treatment options.

g. If patient is high risk for Acute Myocardial Infarction: administer aspirin 162 mg (2 baby aspirin) by mouth.

6. Contact MEDICAL CONTROL. The following may be ordered:

a. NTG 0.3 mg - 0.4 mg SL tablet or spray. NOTE: Administration of NTG is contraindicated if patient has taken Viagra TM within the last 12 hours.

b. Morphine Sulfate 2 mg-5 mg increments IV push.

c. Lidocaine 1 mg/kg - 1.5 mg/kg IV push.

d. Repeat bolus of Lidocaine 0.5 mg/kg -0.75 mg/kg.

e. If patient's BLOOD PRESSURE remains below 100 systolic in response to NTG or Morphine Sulfate, may order further IV Normal Saline.

7. Initiate transport as soon as possible.

8. Notify receiving hospital.

      3.6 CONGESTIVE HEART FAILURE / PULMONARY EDEMA

Severe congestive heart failure (CHF) and/or acute pulmonary edema is caused by acute left ventricular failure resulting in pulmonary congestion. Most commonly these conditions are the result of myocardial infarction, diffuse infection, opiate poisoning, inhalation of toxic gases and severe over-hydration. It is characterized by intense shortness of breath, cough, anxiety, cyanosis, diaphoresis, rales and/or wheezing. In extreme cases, patients will exhibit diaphoresis, restlessness, apprehension and may cough up pink frothy sputum.

ASSESSMENT / TREATMENT PRIORITIES

1. Maintain universal blood and body fluid precautions

2. Maintain an open airway and assist ventilations as needed.

3. Administer high concentration oxygen via non-rebreather mask.

4. Place patient in full sitting position as tolerated.

5. Determine patient's hemodynamic stability and symptoms. Continually assess Level of Consciousness, ABCs and Vital Signs.

6. Obtain appropriate history related to event, including Past Medical History, Medications, Drug Allergies, Substance abuse or Trauma (recent head injury/fracture).

TREATMENT

BASIC PROCEDURES

1. Maintain universal blood and body fluid precautions.

2. Maintain an open airway. This may include repositioning of the airway, suctioning or use of airway adjuncts (oropharyngeal airway / nasopharyngeal airway) as indicated. Assist ventilations as needed.

3. Administer high concentration of oxygen by non-rebreather mask.

4. Place patient in full sitting position as tolerated.

5. Activate ALS intercept, if deemed necessary and if available.

6. Initiate transport as soon as possible with or without ALS.

7. Notify receiving hospital.

INTERMEDIATE PROCEDURES

1. Maintain universal blood and body fluid precautions.

2. Maintain an open airway. This may include repositioning of the airway, suctioning or use of airway adjuncts (oropharyngeal airway / nasopharyngeal airway) as indicated. Assist ventilations as needed.

3. Administer high concentration of oxygen by non-rebreather mask.

4. ALS STANDING ORDERS

a. Provide advanced airway management (endotracheal intubation), if indicated.

b. Initiate IV Normal Saline (KVO) or Saline Lock while in transport.

5. Activate paramedic ALS intercept, if available.

6. Contact MEDICAL CONTROL.

7. Initiate transport as soon as possible with or without paramedics.

8. Notify receiving hospital.

PARAMEDIC PROCEDURES

1. Maintain universal blood and body fluid precautions.

2. Maintain an open airway. This may include repositioning of the airway, suctioning or use of airway adjuncts (oropharyngeal airway / nasopharyngeal airway) as indicated. Assist ventilations as needed.

3. Administer high concentration of oxygen by non-rebreather mask.

4. Place patient in full sitting position as tolerated.

5. ALS STANDING ORDERS

a. Provide advanced airway management (endotracheal intubation), if indicated.

b. Initiate IV Normal Saline (KVO) or Saline Lock.

c. Administer Nitroglycerin (NTG) SL tablet; 0.4 mg (1/150 gr.) or NTG spray if systolic BLOOD PRESSURE is greater than 100. NTG may be repeated in five (5) minute intervals times two (2) as dictated by patient's Blood Pressure.

NOTE: If the patient has taken ViagraTM within the last 24 hours, contact medical control prior to administration of Nitroglycerin.

d. Furosemide (Lasix): 20-40 mg IV push if not currently on diuretics, 40-80 mg IV push if patient is on diuretics. Contact Medical Control if systolic blood pressure is less than 100mmHg.

6. Contact MEDICAL CONTROL. The following may be ordered:

a. Repeat doses of Nitroglycerin SL or spray. NOTE: Administration of Nitroglycerin is contraindicated if patient has taken Viagra TM within the last 12 hours.

b. 1" Nitropaste to anterior chest wall.

c. Repeat doses of Furosemide (Lasix)

d. Morphine Sulfate: 2 mg to 5 mg IV push.

e. Vasopressors: Infusion rates determined by Medical Control.

7. Initiate transport as soon as possible.

8. Notify receiving hospital.






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