Page 119 - 2022 Ranger Medic Handbook

Chest Pain
**Refer to Current ACLS Protocols if tactically feasible and if ACLS equipment and drugs are available. This
protocol assumes no access to ACLS medications or monitoring/defibrillation equipment. Do not delay evacuation if
tactically feasible.
DEFINITION: Possible myocardial infarction or reason to rule out cardiac-related chest pain.
S/Sx (Cardiac): The presence of one or more of the following risk factors increases the likelihood of coronary artery
disease: smoking, diabetes, hypertension, elevated cholesterol, obesity, family history of MI at a young age, and patient
age over 40.
The following are signs and symptoms suspicious for myocardial infarction as the etiology for chest pain: Substernal
chest pain that may radiate to the left arm, neck, or jaw; Pain described as pressure or squeezing; Pain exacerbated
with exertion and relieved with rest; Associated dyspnea, diaphoresis (sweating), nausea, lightheadedness, or syncope; SECTION 3
Tachycardia, irregular heart rhythm, or severe bradycardia; Bilateral rales/crackles in the lungs on auscultation; Signifi-
cant hypertension or hypotension.
MANAGEMENT:
1. Aspirin 324mg PO (nonenteric coated) – chew to speed absorption.
2. Oxygen (if indicated) and pulse oximetry monitoring.
3. If available, Nitroglycerin 0.4mg SL initially, repeat q5min for total of 3 doses if not contraindicated (not hypotensive
and not taking medications to treat erectile dysfunction)
4. IV access with saline lock. Administer 250–500mL crystalloid solution as needed to correct hypotension with frequent
reassessment.
5. After above, treat per Pain Management Protocol.
6. Avoid all exertion. Allow the patient to rest in a position of comfort. Frequently reassess the patient including hemo-
dynamic status.
DISPOSITION: Urgent evacuation. Evacuation platform should include ACLS certified medical personnel and the equip-
ment, supplies, and medications necessary for ACLS care. Do not delay evacuation if unsure of chest pain etiology.
Strongly consider early contact with a medical officer or medical treatment facility for consultation. Frequently reassess
the patient suspected of a noncardiac etiology to ensure stability and accuracy of the diagnosis.
SPECIAL CONSIDERATIONS/OTHER ETIOLOGIES OF CHEST PAIN:
1. The following signs and symptoms MAY suggest a GI etiology such as gastroesophageal reflux disease (GERD):
dyspepsia, dysphagia, burning quality to chest pain, exacerbated by lying flat, foul or brackish taste in mouth. A trial
of antacids or famotidine 20mg PO bid may be useful if evacuation will be delayed.
2. Severe chest pain following forceful vomiting may indicate esophageal rupture. Administer IV crystalloid solution
150cc/hr and Ertapenem 1g IV and evacuate as Urgent.
3. Sudden onset of pleuritic chest pain with dyspnea may indicate pulmonary embolus or spontaneous pneumothorax.
Auscultate the lungs; unilaterally diminished breath sounds suggest pneumothorax which may require decompres-
sion. Administer oxygen, establish IV access, administer aspirin 324mg PO for suspected PE, and evacuate as
Urgent.
4. The following signs and symptoms MAY suggest a musculoskeletal etiology: pain isolated to a specific muscle or
costochondral joint pain exacerbated with certain types of movements, noncentral chest pain reproduced upon pal-
pation. A trial of NSAIDs such as Ibuprofen 800mg PO tid may be useful if evacuation will be delayed.
5. Chest pain with gradual onset and exacerbated by deep inspiration and accompanied by fever and productive cough
MAY indicate lower respiratory tract infection. Consider treatment per Bronchitis/Pneumonia Protocol.

2022 RANGER MEDIC HANDBOOK 105