Chest pain, shortness of breath


• Scene – 12 lead, EKG, oxygen, 324mg ASA
• En route – 20g IV, warm IV fluids 150ml, 3 x 0.4mg NTG sublingual
• Hospital – 12 lead, cardiac workup


• Response to treatment – pain level dropped from initial 7/10 to 5/10 with nitro
• Disposition- cardiac r/o. Chest pain – atraumatic


• Elliot Williams, Paramedic Woodburn Ambulance
• Larry Andres, Paramedic Woodburn Ambulance Service


• David Tauber, EMT Editorial Board
• David M. Spiro, MD, MPH Professor of Pediatrics University of Arkansas Medical Center

• Chest pain

Differential Diagnosis

• Myocardial infarction
• Pneumonia
• Aortic aneurysm
• Musculoskeletal pain
• Arthritis
• Pulmonary embolus
• Pneumothorax
• Trauma (accidental vs. non-accidental)

Patient Workup

• Patient states – chest pain all over and some shortness of breath. Chest pain started 4 days ago and left arm has been hurting for 4 months. He was very sweaty a few minutes ago, thinks he might have a fever. Pain described as general, not able to describe it more.
• Caregiver states – patient started complaining of increased chest pain 30-60 minutes ago, did not give any nitro or aspirin prior to arrival of EMS. No recent falls. States that patient is a hospice patient and has a DNR, but provided no paperwork.

Physical Exam

• Patient is atraumatic, no significant physical findings
• EKG – SR. No rhythm changes or ST elevation on 12 lead.
• CBG – 158

Editor’s Notes

Chest pain, elderly DNR pt. I think the work up was great, treatment entirely appropriate save the lack of ASA administration (which may have been given). Also interesting on no oxygen for a 91 O2 sat. Discussion on oxygen target for pre vs post arrest pt. Teaching note: could be used to discuss care of hospice pts and the lack of paperwork to support the DNR. Especially the need to still treat the pt who is not yet dead. Could also be used to discuss the diff dx of chest pain focusing on the sputum production and pneumonia ~ David Tauber, Director of Paramedic Training, Yale New Haven Sponsored Hospital

Suggested References

Chest Pain Evaluation by EMS Personnel


• Gender: Male
• Age: 90 years
• Height: Not Available


• Temperature: 98.4 F/36.9 C
• Blood Pressure: 113/62
• Heart Rate: 68
• Respiratory Rate: 20
• Pulse Oximetry: 91% RA

Signs and Symptoms

Chest pain; shortness of breath; coughing up mucus


• PMH: Coronary heart failure (CHF), afib, anxiety, diabetes, shortness of breath, kidney disease, benign prostatic hyperplasia (BPH), chronic pain.
• Allergies: Ambien
• Dispatch info: Chest pain


• Lives in memory care facility


• Tylenol, allupurinol, diltiazem, docusate, fentanyl, haloperidol, hydrocodone/apap, omeprazole, Prilosec, sertraline, Bactrim DS, tamsulosin, finasteride, morphine PRN, nitro PRN, olanzapine PRN, oxygen PRN

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