Chest Pain and Aspirin-It is Really Important!

Chest Pain and Aspirin-It is Really Important!

While looking at cases with a primary provider impression of  “CV-Chest pain (cardiac, angina, non-STEMI)” and the three “CV-Chest Pain (STEMI) of xxxxx” versions, it is noted that many of these patients are not receiving aspirin by EMS.

Review

Aspirin is not administered for pain relief in the presence of chest pain.  It is given because it has antiplatelet properties and numerous studies have proven that it prevents further clotting within minutes of being administered. It is considered to have a Class I indication for use in STEMI patients by the American Heart Association (AHA) meaning there is strong evidence and /or agreement that it helpful and good for the patient. Per the Tidewater EMS (TEMS) Medication sheet, “aspirin’s antiplatelet property works by inhibiting the production of thromboxane, a platelet binding agent, and is different from other common blood thinners such as plavix or Coumadin.”  This means that further thrombus formation is prevented which can limit additional damage.

Protocol

For patients with chest pain that is consistent with cardiac etiology, the TEMS protocols state providers at all levels (EMT and above) will perform a 12 lead EKG and then administer aspirin (ASA) 324 mg on standing orders.

Next, nitroglycerin (NTG) SL should be administered (EMT and Advanced level providers would need physician order).  The patient’s BP should be 90 systolic or above with an IV or 110 systolic if there is no IV.  SL NTG should be administered every 3-5 minutes up to three doses or until chest pain has reached 0/10.  Remember to ask the patient if they have taken any sexually enhancing medications in the past 24-72 hours first.

If pain persists or is not decreasing, Morphine and Transdermal NTG may be given.  Morphine can be administered concurrently with NTG.  Transdermal NTG should be administered early if the patient can’t tolerate SL NTG.

The TEMS protocol for Chest pain is here:   TEMS Chest Pain Protocol

Aspirin Precautions

  • Patients who have taken ASA prior to your arrival should be given the difference up to 324mg. If the patient took one 81mg ASA, you should administer 243mg (3 tabs).
  • You should avoid giving ASA to the following patients:
    • History of GI bleeding or other bleeding disorders
    • History of recent (within 14 days) surgery
    • Allergy to ASA
  • Contact medical control to determine if it can be given in the following situations:
    • Patients with a sensitivity to ASA
    • Patients taking anticoagulant “blood thinners” like Heparin, Lovenox, Coumadin, Effient, Warfarin, Xarelto, Paradaxa. (Patients taking Aggrenox, Ticlid or other antiplatelets can receive ASA)

Documentation

If you are suspecting that the patient is having cardiac chest pain and that is the basis for your treatment plan, your primary impression should reflect chest pain with either STEMI or (cardiac, angina, non STEMI).  When one of these are selected, you are expected to treat the patient with the chest pain (cardiac) protocol including ASA, NTG and of course a 12 lead.

Every medication given (including oxygen and saline) and procedure performed should be listed in the appropriate section.  This includes pertinent medications (ASA, NTG)  and procedures performed (12 leads) prior to our arrival.  If the patient took or was given ASA shortly before 911, that should be listed in the medication section with the time, dose, etc. Instructions for documenting pertinent items that occurred before we arrive can be found here:  https://www.vbems.com/2017/01/03/documentation-proceduresmeds-pta/

If you feel that that the patient is not having a cardiac issue and do not feel NTG and ASA are warranted then the primary impression should be something else such as “Injury-thorax” if traumatic in nature, “Pain-chest (not cardiac or injury)” for soreness and muscle aches and other non-cardiac chest pains not caused by injury, or a more appropriate choice like asthma exacerbation, CHF, dysrhythmia, etc.

Further information on which choice is best for your chest pain patient can be found here: https://www.vbems.com/2017/03/30/how-to-elite-chest-pain-provider-impressions-for-bls-and-als-patients/

Goals for Chest Pain

  • All patients 35 and older with any chest pain will receive a 12 lead (other signs and symptoms as well)
    • 12 lead will be performed within 10 minutes of patient contact
    • STEMI 12 leads will be transmitted within 5 minutes and with a radio call
    • 12 leads will be transmitted to the hospital and uploaded to the patient report
  • STEMI patients will have an onscene time of 15 minutes or less
  • All cardiac chest pain patients will receive ASA and NTG as appropriate

 

Other reference links:

http://circ.ahajournals.org/content/117/2/192

http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/cardiology/acute-myocardial-infarction/#s0080

http://tidewater.vaems.org/docman/protocols/2016-tems-protocols/2155-2017-03-08-tidewater-ems-regional-medical-protocols-with-appendixes/file