Dear Providers,

We are often met with a chief complaint, sometimes many chief complaints. I have seen two types of evaluations in the pre-hospital area. First, the provider anchors on a chief complaint and strictly follows the protocol. Secondly, the provider takes a chief complaint, considers the possibilities, and utilizes the appropriate protocol assistance. The latter is the correct way to care for emergent situations. During our airway month, we will precede the lecture with a chief complaint and develop a differential diagnosis list to consider for the patients you are treating.

This first week discusses the patient who complains of chest pain. Our cardiac chest pain patient would fit nicely into our chest pain protocol. However, before we can give aspirin and nitro, we must evaluate the patient for other possibilities. I recently reviewed a run in which a patient was found at the bottom of the stairs. The patient’s husband reported that she was complaining of chest pain. Here the provider used the chest pain protocol and administered aspirin and nitroglycerin. The actual chest pain was from rib fractures, a skull fracture, and subarachnoid hemorrhage. The provider tried to help this patient with a protocol they felt comfortable using. It is what I mean by making the patient fit a protocol instead of utilizing the appropriate protocol assistance which would be found for this patient in the trauma protocol. Sometimes we need to take the path less comfortable to benefit the patient properly. Certainly, when you’re unsure, you can’t be wrong in getting the required EKG per the chest pain protocol. But the following factors start to clarify your decision-making process.

Chest pain needs broken down methodically.

When did the pain start?

What were you doing during the onset? Rest or exertion?

What does it feel like?

• Tearing to the back may mean a dissection; check blood pressure in both arms.

• Dull aching with radiation to the jaw or arms; think cardiac.

• Pressure; think cardiac.

• Can’t describe; think cardiac?

• Burning; think gastric origin

• Pleuritic; less likely cardiac, but could mean PE, pneumothorax, pneumonia, or chest wall injury

Duration?

• Brief is usually not a STEMI.

• Constant with new onset is a cardiac concern.

• Intermittent, what brings it on, helps with the differential.

After the history and factors describing the chest pain, the next step is to form a differential. List the possibilities of chest pain and then evaluate this patient. You will get to the right decision as you start with a broad differential and narrow it down rapidly with your history, physical, risk factors, and surrounding critical points, like trauma, exertion, pleuritic nature, abdominal origin, back involvement and gaining information as it is brought to your attention. Never fear new information

CHEST PAIN DIFFERENTIAL

1. Myocardial Infarction (sudden onset)

2. Angina (exertional or unstable angina at rest)

3. Pulmonary Emboli (pleuritic in nature SOB)

4. Pneumonia (fever, cough, sob)

5. Trauma (tender after injury)

6. Pneumothorax (pleuritic and sob)

7. Gastritis (ulcerative illnesses and burning pain)

8. Peptic Ulcer (like gastritis presentation)

9. Pancreatitis (severe epigastric, supraumbilical pain with back pain as well)

10. Cholecystitis (right upper quadrant pain and tenderness positive Murphy sign)

11. Boerhaave vs. Mallory Weiss Syndrome (usually after forced vomiting)

12. Dissecting aortic aneurysm (tearing pain radiating to back with right side B/P higher than left arm B/P.)

13. Gastric or bowel perforation (severe epigastric pain with a very firm abdomen)

14. Splenic origin (trauma or illness like mono that can cause splenomegaly)

15. Esophagitis/ Esophageal perforation 

The key to great patient care is listening to the patient, family, friends, and bystanders who can help. Information gathering is the best way to start to narrow the differential. It will give your patient a much better chance and improved outcomes.

Thank you for taking the time with our Monday Morning Medical Director Message. See you next week for our shortness of breath differential.

Sincerely,

Don Spaner, MD

EMS Medical Director

Differential Diagnosis - SOB - March 13, 2023

Dear Providers,

Welcome back for the second installment of our Differential Diagnosis series. This week we will consider a very common 911 call: Shortness of Breath (SOB), which has a vast differential, considering that the source may not always be a pulmonary emergency. In fact, the sense of SOB may be seen as a compensatory reaction to a metabolic acid state. The patient compensates for their metabolic acidosis by hyperventilating and blowing off CO2 to attempt to correct the body’s PH.  

It is seen with DKA, shock or Aspirin OD, to name acidotic inciting events, or is it an actual oxygen caring capacity issue seen with profound anemia or blood toxins like carbon monoxide, cyanide, or nitrate toxicity causing methemoglobinemia? Is this a patient exposed to chemical toxins like chlorine or phosgene gas? This is a critical consideration if you are arriving at an industrial environment and multiple patients are SOB. Is there trauma causing pulmonary contusions, pneumothorax, or hemothorax, all impeding gas exchange? Is this a cardiac patient suffering from heart failure exacerbation? Or is it an SOB diabetic who is well known to have SOB as their most common complaint while suffering an acute myocardial infarction? Is this a pulmonary patient suffering from COPD or asthma exacerbation? Asking PMH questions is always part of an AMPLE history.  

Has there been a recent illness, fever, cough, or sputum production, which may indicate pneumonia, bronchitis, or URI? Is this an at-risk coagulopathy patient who may be presenting with a pulmonary embolus?  

A few questions to ask:

• Ask about birth control mixing with tobacco.  

• Ask about other family members who have had clotting issues.  

• Ask about recent surgeries or immobility, including long car rides or plane rides.  

• Ask about cancer issues frequently associated with coagulopathies, including pulmonary emboli (PE.)  

Any of these supporting questions may raise the pulmonary embolism differential way up on your list, especially if it is associated with a patient with pleuritic pain, hypoxia, hypocarbia, and tachycardia. If this patient is also tachycardic or, even worse, hypotensive, PE must be a serious consideration.   

Your hard work, attention to detail, and keeping your possibilities open to consideration will benefit your SOB patient immensely. Remember to take your 30-second time out so we can listen carefully to all of your hard work. Thank you for all you do. 

Below is the Differential Diagnosis list for your consideration. Please review this as you consider how to narrow the differential safely to help your patient get the best care.

1. Anemia (ask about bleeding)

2. DKA (History and glucose check)

3. Myocardial Infarction (12 lead, Diabetic, elderly)

4. COPD/Asthma (breath sounds and PMH)

5. Cardiac asthma (Heart failure, JVD, Edema)

6. Pneumonia (fever, cough, sputum, and illness)

7. Pneumothorax

8. Sepsis

9. Shock

10. Trauma

11. Poisoning (aspirin, nitrates, cyanide, chlorine gas, phosgene gas, and carbon monoxide)

12. Pulmonary embolism (PE risks reviewed)

Sincerely,

Don Spaner, MD

EMS Medical Director

Differential Diagnosis - Headache - March 23, 2023

Dear Providers, 

Thank you for taking a minute to review the third letter of our series of Differential Diagnosis.  In the case of a patient suffering a sudden and severe headache, emergency physicians are highly concerned and classify as two types: the worst or the first.  There are plenty of patients who suffer from frequent headaches.  These can range from migraines, cluster, or tension headaches.  Although debilitating, these types of headaches do not result in neurologic devastation or death.  We can usually assist these patients, but these chronic headache patients do not cause the ED doctor worry.  However, when a chronic headache patient reports that this is the WORST headache they have ever had, we become very concerned.  

The other headache group of concern is the patient who never gets headaches and describes this headache as the FIRST headache they can remember.  As we decide if your headache 911 call is an emergency, remember the WORST or FIRST rule.  The next is to develop a differential that considers life-threatening, disabling, or neurologically devastating.  Headaches from sinusitis, viral illness, pharyngitis, TMJ, otitis media, dental infection, the typical migraine tension or cluster headache, do not fit these concerns.  

The following is the list of headache emergencies: 

1. Glaucoma-these are the patients with painful headaches associated with a steamy-looking cornea and visual loss.  This narrow angle glaucoma needs immediate emergency intervention from the ED Physician as we prepare them for ophthalmologic emergency intervention. 

2. Meningitis-this ill-appearing, frequently febrile, and possibly altered mental patient, frequently suffers from nuchal rigidity. It requires rapid diagnosis, septic care, lumbar puncture, and antibiotics for bacterial meningitis while considering steroids and other agents for viral or fungal origins.  These are true medical emergencies. 

3. Sub Dural Hematoma (SDH), although more common in the elderly head injury patient, any head trauma patient with loss of consciousness, and suffering from altered mentation or headache, will undergo imaging rapidly to evaluate and rule out an SDH. 

4. Sub Arachnoid Hemorrhage (SAH)-an extreme headache emergency.  These usually have a sudden onset from a ruptured aneurysm, and the mental status can rapidly deteriorate.  I have seen these events with weightlifters, sneezers, during intercourse, and any number of events that subjects a patient to sudden vascular force, including trauma.  Fortunately, if these patients seek immediate help (less than 6 hours from onset), the head CT without contrast is nearly 99% effective in identifying a SAH brain bleed. 

5. Temporal Arteritis is another emergent headache to consider for the 911 headache call.  These patients are tender over one side of their temple, which represents the location of the temporal artery.  These patients will require lab tests, emergent steroids, and a temporal artery biopsy to prevent vision loss. 

6. CO poisoning is a critical headache patient that must be considered, especially during the cold months.  Fortunately, your equipment usually is alarming with elevated CO levels.  Patients’ headaches usually start with levels of CO greater than 10.  These patients need 100% O2 therapy, realizing that the room air half-life of CO is 240 minutes, but 100% NRB drops this to less than 90 minutes.  The CPAP high flow O2 can reduce CO half-life to 20 minutes. 

7. CVA- stroke truly should be considered with any headache patient, so complete a Cincinnati Stroke Test, as well as a VAN. A glucose check should be done on all headache patients as well.  

8. Cerebral Venous Sinus Thrombosis- this is rare but can cause blood not to flow out of the brain.  Here we think of risk factors for patients with headaches who may suffer from this life-threatening headache.  Post-partum, Sickle Cell, cancer patients, coagulopathy patients, and even profound obesity are some risk factors for cerebral venous sinus thrombosis. 

9. Pre-eclampsia-this third trimester, or a recent post-partum mother suffering from hypertension, headache, hyperreflexia, and proteinuria are true medical emergencies requiring blood pressure control and IV magnesium. 

As always, thank you for all you do to provide the best pre-hospital care for our patients.  As my old commander always said, “Teamwork makes the dream work.”  I hope to see all of you for our final installment of our Differential Diagnosis series. 

Sincerely, 

Don Spaner, MD 

EMS Medical Director 

Differential Diagnosis - Back Pain - March 27, 2023

Dear Providers, 

Thank you for taking the time to review the Differential Diagnosis series. This was chosen because it is a common 911 complaint and frequently is met with a sense of a nuisance call, and the call can be a critical life-threatening event. 

After an exhausting day, the alarm goes off for a 50-year-old male with a history of hypertension and chronic back pain. You arrive to find him in significant distress.   Tonight, he can’t get comfortable, even while lying very still. He has been a laborer his whole life and is used to chronic back issues. He takes Motrin and his blood pressure pill daily) His vitals are 200/120, and his pulse is 110 BPM. He is breathing 22 breaths per minute and is diaphoretic and vomits. You assist him onto the cot and take him to the ambulance. In the squad, he is in severe pain, and you administer 1mg of Dilaudid IV and 4mg of Zofran IV with some relief. You start the exam, and he has good heart sounds and clear lungs, but as soon as you feel his abdomen, you feel a pulsatile mass. Certainly, we can all feel the critical nature of this call, and Dissecting Aortic Aneurysm is very high on your differential list. You repeat the vitals, and he still has a BP of 190/110.  

You know that your current use of written protocols uses Labetalol for Pre-eclampsia and Eclamptic hypertension. However, you explain the situation, and the ED doctor orders Labetalol 20 mg IV and prepares for a critical patient arrival.   The issue is\ many critical back pain patients do not make the diagnosis so easy. We realize the back pain patient can have a simple back strain or herniated disc without neurologic deficit or arthritis issues, but our focus is not to miss life-threatening, limb-threatening, or disabling emergencies. The following are back pain emergencies we simply can’t miss.

1. Aortic Dissections may be in the ascending aorta and can be associated with a STEMI (the coronary arteries arise from the base of the aorta). Any STEMI with tearing back pain should have aspirin, Brilinta, and Heparin held until the ED ensures the STEMI’s origin is not from an Ascending Aortic Dissection. Descending Aortic Arch Dissections and Abdominal Aortic Dissections require emergent medical care and frequently surgical care. Tearing back pain with hypertension requires pain medication and BP evaluation in both arms, with concern when the left arm BP is much lower than the right arm BP. Getting these patients to a hospital with immediate Vascular Surgery availability is critical for patient survivability.  

2. Pyelonephritis is a profound infection of the kidney. The back pain is usually on one flank or the other and may be associated with fever and dysuria. These patients require septic care, IV fluids, and IV antibiotics rapidly.

3. Obstructive renal uropathy. These are generally kidney stone patients, and many women describe this pain as childbirth-like pain. It sounds awful and feels even worse. Ask about bloody urine, discolored urine, and PMH. These are more common on hot days when the pt is dehydrated. However, we see these year-round. The associated renal injury, sepsis, and severe pain make this back pain complaint a true emergency.

4. Cauda Equina, this is a neurosurgical emergency. The spinal cord ends at L1 into what is called the conus. The nerves distal to the conus are a tail of nerves referred to as the cauda equina. When a severe disc herniation impinges on the cauda equina, the patient loses the ability to urinate and has stool incontinence without feeling stool come out of the rectum. They also frequently have leg weakness. All back pain patients should have an inquiry about their ability to urinate and whether they have had incontinence of stool. This patient needs to go to a neurosurgical center.

5. Pancreatitis is an extreme emergency in which the pancreas inflames and causes both supra-umbilical abdominal pain and back pain. These patients need IV fluids, pain management, and admission while the source is identified.

6. Diverticulitis: When the colon suffers from diverticulitis, there is frequent abdominal pain, but because the colon sits in the retroperitoneal area, there is also frequent back pain, so this frequent infection must be on our back pain differential.

7. Cholecystitis, the gallbladder, is also a common infection, and the pain from an infected gallbladder frequently refers to the right or even left scapula. Remember the Murphy sign. Gently press under the right lower ribs, and have the patient breathe in. The infected gallbladder will move down and touch your fingers. It will cause the inspiration to stop, and the patient will wince with pain. That is a positive Murphy sign.

8. Pulmonary emboli, these patients suffer from pleuritic chest or back pain. The shortness of breath patient with back pain should always be considered for possible PE.

9. Epidural abscess is a very sneaky and frequently missed diagnosis. The neurologic deficit in the setting of back pain may be associated with a fever, IV drug abuse, immunocompromised, cancer, AIDS, epidural anesthesia, or spinal surgery. The diagnosis is made in the ED with the use of MRI, but if we suspect this early, we start septic care and IV antibiotics rapidly.

These are the differential diagnosis events we can’t miss. I hope this helps with those 0100 calls we may feel aren’t a true emergency. As always, thanks for everything you do, and please know how much we appreciate our pre-hospital providers.

Sincerely, 

Don Spaner, MD 

EMS Medical Director