Acute onset, 7/10 chest pain radiating to left arm and neck


• NTG (no relief after EMS admin)
• Approved for diltiazem by medical control, given in ER as approval occurred within minutes of arrival


• Chemical conversion in ER with diltiazem


Elliot Williams, Paramedic Woodburn Ambulance


David Tauber, EMT Editorial Board


• Atrial fibrillation

Differential Diagnosis

• Arrhythmia
• Myocardial infarction
• Non-cardiac chest pain
• Pulmonary embolus
• Pneumonia
• Costochondritis
• Pericarditis
• Aortic Aneurysm

Patient Workup

• IV
• Oxygen
• Monitoring

Editor’s Notes

Two comments on the medics questions: one was “have you ever had a cardiac BEFORE” possibly implying to pt this is cardiac origin now. Try to leave out word before. The second comment was use of the word “radiating” which may not be known to a lot of patients. I agree the “dirt” is the correct treatment and have to wonder why it was not done earlier in the call. Another possible treatment includes an opiate analgesic

– David Tauber, Director, Yale New Haven Sponsored Hospital Paramedic Program


• Gender: Male
• Age: 52 years
• Height: Not Available
• Weight: Not Available


• Temperature: Not Available
• Blood Pressure: 220/130
• Heart Rate: 140
• Respiratory Rate: 20
• Pulse Oximetry: 98% RA

Signs and Symptoms

Midsternal tightness, pressure; with occasional worsening stabbing pain; pain radiates to left neck and left shoulder. Position of comfort is on his knees with arms above his head, hands locked behind his head. Patient states this relieves the “pressure”.

History Medical

• Previous myocardial infarction
• Surgical “stent” placed in coronary artery s/p MI
• Type 2 Diabetes Social
• Works at Walmart
• Light drinker
• Denies tobacco use


• “Blood thinner”
• NTG prn – took 2 NTG tabs prior to EMS arrival without relief of chest pain

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