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Cardiac Syndrome X
Hi ya'll
I know the medical (hospital and post diagnostic treatment) for Cardiac Syndrome X. But what should be the prehospital treatment for patients experiencing acute episodes of the syndrome. Often they have chest pains and sometimes they may present with facial palsy (TIA symptoms) along with the normal peripheral cyanosis and poor O2 sats.
To treat such patients with morphine seems to me to be relatively contraindicated as it vasoconstricts already constricted blood vessels which is the cause of some of the presenting symptoms.
Nitro is a sound tx, but what about entonox Q. Would you give entonox to someone who has TIA symptoms with non cardiac chest pains. The syndrome is vasoconstriction - differentially from Angina as there is no apparent atheromatous plaques (although there may be , but this is coincidental).
So, patient with chest pains with Cardiac Syndrome X do you give Oxygen or something else?
Mike
I know the medical (hospital and post diagnostic treatment) for Cardiac Syndrome X. But what should be the prehospital treatment for patients experiencing acute episodes of the syndrome. Often they have chest pains and sometimes they may present with facial palsy (TIA symptoms) along with the normal peripheral cyanosis and poor O2 sats.
To treat such patients with morphine seems to me to be relatively contraindicated as it vasoconstricts already constricted blood vessels which is the cause of some of the presenting symptoms.
Nitro is a sound tx, but what about entonox Q. Would you give entonox to someone who has TIA symptoms with non cardiac chest pains. The syndrome is vasoconstriction - differentially from Angina as there is no apparent atheromatous plaques (although there may be , but this is coincidental).
So, patient with chest pains with Cardiac Syndrome X do you give Oxygen or something else?
Mike
Replies to This Discussion
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Permalink Reply by Scott RB on -
NTG seems like it would be fine As for morphine, I've always known it to generally be associated with vasodilation. I did cursory search for information on morphine and any vasocontrictive effects that it may have. I could only find information regarding placental-fetal tissue vasoconstriction induced by morphine.
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Permalink Reply by Mike Bjarköy on -
I meant to treat patient with morphine seems like a good idea but oxygen seems to be relatively contraindicated...
I edited this so many times it just became garbled. sorry.
Mike
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Permalink Reply by TheCannulator on -
Pain is pain.
Treat it.
Entonox would be fine.
Morphine actually vasodiates and slow AV conduction. So may actually be supportive in these patients.
Angina/Ischaemia doesn't require atheroma.
Change your focus to chest discomfort (whatever the ppteint describes) that may be cardiac in origin is cardiac in origin until proven otherwise. Syndrome X is still ischemia. So good Basic cardiac cares till applies.
(just read your repost: so apart from the Morph bit, no change give the gas!)
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Permalink Reply by Mike Rubin on
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Why would O2 be contraindicated?
Mike Bjarköy said:I meant to treat patient with morphine seems like a good idea but oxygen seems to be relatively contraindicated...
I edited this so many times it just became garbled. sorry.
Mike
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Permalink Reply by dr-exmedic on -
I wouldn't touch specific treatment for this with a ten-foot pole. If they have had it long enough to get a diagnosis, and have been on meds for it, yet are calling 911, it's probably because their symptoms are severe or different enough from their usual symptoms that EMS should assume that something unusual is happening. For example, someone with facial palsy and chest pain could be dissecting a carotid; folks with just chest pain may be having a full-blown ischemic event rather than just CSX.
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Permalink Reply by BostonMedic109 on -
First Cardiac X Syndrome is almost (or at least most commonly) in post menopausal women and is actually only established post extensive investigation (angiography etc). Though someone might have had a previous event identified as Cardiac X Syndrome, there is no way to differentiates a ongoing event as such to after the event. Patients sensitive to Cardiac X are also prime for "real" events thus the most prudent course is to treat what you see or hear," walks like a duck..." Therefore treat as if real ACS. As to MS probably time will answer the whether to or not to.( Bulk of evidence the MS and lasixs NTG for AMI) I would tend to NTG for the vasodilitaion and O2 and possibly fentanyl And like I tell new medics your job isn't to Rule out it's to stabilize & manage so my general statement is," If you would have treated this patient as an AMI when you were an EMT-B do the same as a medic, for there is no machine or assessment that is 100% sensitive/specific to ACS"
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Permalink Reply by Mike Bjarköy on
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Thanks for all your replies to date.
One of my jobs is to identify better patient care packages and pathways for regular callers and the reason for the post is that I have such a frequent caller with Syndrome X which calls every 2 to 3 days.
Each time with pain in chest which is pin point specific on the right side (3rd intercostal space, pain in neck (not jaw) both sides and able to point to the pain (carotid artery) and each time has a facial palsy. Each time taken to the Emergency Department and no specific treatment is taken and no CT/MRI investigation are undertaken - as they already know what the problem is and that it's self limiting.
Crews are becoming concerned about their level of care and questioning their own treatment plan -
"should we give oxygen under the new guidelines - Sats are over 94%, not compromised",
"concerned about over-exposure to regular morphine shots and the potential for dependancy"
so they brought their concerns to my doorstep. We're tending to turn away from defensive medicine and look toward patient specific needs rather than what is easiest and historically correct for the standard patients we encounter.
One of the things I am considering is prescribing oromorph for the patient, this will offer pain relieve at the onset of symptoms. The other thing I have set up is a 24 hour hotline to the on call community doctor - who will attend first and assess.
thought you would appreciate a bit of background.
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Permalink Reply by BostonMedic109 on
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With these updates I want to modify my earlier,"Treat every Chest Pain as possibly being the big one" In my past life we had to deal with a great number of "frequent flayers" we were able to modify the SOPs with the support of all the other involved disciplines: Primary care MDs, Visiting Nursing ,Social Work etc. We would create a specialized care plan for the specific patient such as documenting the repetitive non emergent present ion and an alternative treatment paradigm which everyone signed off on, some that the poor EMT-B or P at the bottom of the totem pole wasn't the one holding the bag at 2AM. In this way there was a defined care plan agreeable to all parties. We found that the ED didn't want to see or manage these patients every two or three days either.
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Permalink Reply by TheCannulator on
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Mike nothing changes in the care of an acute compromising episode, because your don't want crews to miss the "real one" so to speak. Having a community based plan where really pain relief is as important as perfusion is a much better process.
It's very easy for crews to slip into a blase` approach when confronted with the regular caller.
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Permalink Reply by Mike Bjarköy on
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Absolutely - that's what I don't want to happen here, just because the patients accessing the same crews again and again, my fear is crew complacency. The care plan is as much to do with educating the crew as it is educating and treating the patient.
TheCannulator said:Mike nothing changes in the care of an acute compromising episode, because your don't want crews to miss the "real one" so to speak. Having a community based plan where really pain relief is as important as perfusion is a much better process.
It's very easy for crews to slip into a blase` approach when confronted with the regular caller.
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Permalink Reply by Mike Bjarköy on
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Good to know you've done similar pathways - comforting to identify with people who have faced similar challenges.
BostonMedic109 said:With these updates I want to modify my earlier,"Treat every Chest Pain as possibly being the big one" In my past life we had to deal with a great number of "frequent flayers" we were able to modify the SOPs with the support of all the other involved disciplines: Primary care MDs, Visiting Nursing ,Social Work etc. We would create a specialized care plan for the specific patient such as documenting the repetitive non emergent present ion and an alternative treatment paradigm which everyone signed off on, some that the poor EMT-B or P at the bottom of the totem pole wasn't the one holding the bag at 2AM. In this way there was a defined care plan agreeable to all parties. We found that the ED didn't want to see or manage these patients every two or three days either.
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Permalink Reply by Chasity Deloach on -
If someone has chest pain I automatically put them on 2L O2 via NC!! If SATS are in low ranges, depending on their PMHX, I may put them on more O2 via another source!! (ex: NRB, Ventri mask, simple mask, etc...)
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