Call PAPPA for Chest Pain – A helpful Mnemonic for Paramedics and EMTs

If you’ve been an EMT or Paramedic for more than a few days, chances are that you’ve met someone complaining of chest pain. “Chest Pain” calls are one of the most common reasons for an ambulance being dispatched and for good reason, a patient having pain in their chest can be experiencing a host of medical conditions ranging from something as simple as a strained muscle all the way to imminent cardiac arrest. 

Most people could probably state what are supposed to be the classic symptoms of a heart attack. Medical people have been describing them for years as “Chest pain that starts in your chest and goes down your left arm, shortness of breath, fatigue, and a feeling of impending doom.” However as healthcare providers, we know that not every “heart attack” or “myocardial infarction” produces appreciable chest pain as a symptom and that no two people feel heart attacks the same way. It is well known that diabetic patients frequently experience “Silent MIs” and may not feel any pain due to nerve damage caused by hyperglycemia. It also should be well known that there can be a big difference in the symptoms experienced by men and women as well as among different ethnic groups. Always remember, the “classic symptoms” of a heart attack are generally how the symptoms of the condition might be experienced by a 45 year old white male. A 52 year old black female may experience the symptoms of an identical blockage quite differently. A person with type II diabetes may not have any of the classic symptoms at all.

It is also important to note that there are multiple conditions that could cause a patient to complain of pain in their chest and not all of them are cardiac related. Trauma patients may experience thoracic trauma and injure any of the anatomical structures within their chest. Medical patients may have a problem come up with any of the organs and/or organ systems within the area. Remember that all trauma patients must receive a medical exam in order to rule out any underlying medical complaint that exists concurrently to their traumatic injury. Never think that anything is “just” something. Always do a full assessment.

So how do we remember to look for what we need to look for when evaluating a patient with chest pain? A thorough physical examination and a few tests are definitely in order, however I recently learned a new acronym that might help: “PAPPA”

A “PAPPA” chest pain assessment helps the healthcare provider remember to check for the 5 most immediately dangerous conditions that could cause chest pain. These are:

P – Pericarditis

A – Acute Coronary Syndrome

P – Pneumothorax

P – Pulmonary Embolism

A – Aneurysm

Any one of those conditions could prove fatal for a patient if they aren’t caught during an exam and all of them benefit from immediate identification and treatment. By remembering to check for them you’re doing your patients a big favor, not to mention helping yourself avoid a lot of headaches for missing something important.

Here’s how you check.

Physical Exam – I advocate that you should do the same in-depth exam on every patient you treat (See HERE for more of my writing on EMS Assessments) but for patients needing a PAPPA exam this is of paramount importance. Make sure to document the following:

Lung Sounds

A MANUAL blood pressure taken on EACH arm – It is very important to check for any difference in systolic blood pressure between the arms as well as to listen for “pulsus paradoxus” or the blood pressure beats disappearing upon the patient’s inspiration due to an increase of intrathoracic pressure (See HERE for an in-depth look at blood pressures and what you can learn by taking them)

Palpate the patient’s abdomen for tenderness, any appreciable masses, or pulsation.

Note the condition of the patient’s skin (Color, temperature, and moisture)

Check for pedal edema in both legs.

Obtain the patient’s description of the pain in their own words – Don’t lead the patient or actually use any of these terms before they say them which might convince the patient that they’re feeling something they’re not. Ask open-ended questions that cause the patient to think and elaborate on their own. Find out if the pain is:

“Sharp” like a knife or a needle

“Dull” like an ache or a bruise

“Pressure” like being squeezed or sat upon

“Ripping or Tearing” (“I feel like I’m being ripped in half”)

Any other description

Check for any provocative or palliative features – Anything that makes the pain worse (“provocative” – Provokes more pain) or better (“Palliative” – relieves pain). These can be:

Exertion – Did the patient walk anywhere? Does walking or other mild physical exertion make the pain worse? Also check for “Exertional Dyspnea” which is an increase in difficulty breathing and/or shortness of breath caused by mild exertion. Increased exertional fatigue, where the patient gets much more tired more quickly than usual with mild exertion is important to check for as well.

Respiration – Does breathing in and out make the pain worse? Have the patient take a deep breath. Does that cause a sharp increase in pain? Is the patient coughing? Does the cough increase their pain?

Treatment – While not completely reliable, some relief of pain with treatments such as nitroglycerine and oxygen can be diagnostic. However on it’s own, relief of chest pain following administration of nitroglycerine is not a reliable indicator of the presence or absence of cardiac ischemia (Chest Pain Relief with Nitroglycerine Does not Predict Active Coronary Disease)

Review the patient’s history, both recent and farther back. See if they’ve been having warning signs for the last few days. aak if they’ve been having palpitations, have been feeling sick, have been running a fever, or may have been to the dentist lately. Also ask them if they’ve been off of their feet lately such as being on a long trip in a car or airplane or perhaps even in bed recuperating from an illness or injury.

Use your tools.

Obtain a QUALITY 12-lead EKG tracing as soon as possible on chest pain patients. Obtain your first 12-lead where you first find your patient (Yes, I’m telling you to lug your monitor all the way in the house). You should also withhold treatments like oxygen and/or nitroglycerine until after you’ve performed your first 12-lead. You’re not delaying care by doing this, you’re speeding it up by hours. EKG changes indicative of a STEMI can be completely normalized by oxygen and nitro administration within as little as a few minutes. If you treat before you take the 12-lead you could miss a STEMI that would benefit from immediate admission to a cath lab. Don’t do this. (For more on 12-leads, see HERE) I support every ambulance having the ability to obtain a 12-lead. I even support them for first responders. Your EMT-B squad should be obtaining and transmitting 12-leads, even though I don’t support you trying to read them without proper education.

Remember: A 12-lead EKG CAN NOT rule out an MI. A person with a completely normal 12-lead EKG can still be having the big one. If you see an MI on a 12-lead, you know the patient is having a STEMI. If you don’t see one, you don’t know whether they’re having one or not.

Place the patient on a regular cardiac monitor and document the rate, rhythm, changes in the rate and/or rhythm, and the presence of either ventricular or atrial ectopy.

Document pulse ox readings, both initial room air saturation and post oxygen administration.

If there is shortness of breath or dyspnea, consider monitoring ETCO2.

Here’s what you’re looking for with each condition (This is not intended to be an exhaustive list of symptoms):

P – Pericarditis: This is an infection of the outside lining of the heart. It can be either bacterial or viral and recent dental work is a common precipitator of the condition. Pericarditis can cause symptoms closely resembling a STEMI and can cause the coronary blood vessels to become irritated and spasm causing a blockage. (For more on pericarditis, click here) Look for nonspecific chest pain across the spectrum of patient populations that has the hallmarks of myocardial ischemia. A 12-lead EKG might show a wide range of ST changes that do not make sense or follow classic injury patterns.

A – Acute Coronary Syndromes: This is a fancy term for a myocardial infarction, a blockage in one or more of the coronary blood vessels that causes ischemia further down the line. It can be an ST Elevation MI (STEMI), a Non-ST Elevation MI (NSTEMI), or angina (stable or unstable). Look for provocative or palliative features, a non-specific or dull pain with or without radiation, shortness of breath, diaphoresis, and changes in a 12-lead EKG. Always be suspicious that your patient is having an MI.

P – Pneumothorax: Patients can experience a pneumothorax, or air escaping from a lung and becoming trapped in the pleural space, from either traumatic or medical causes. A “tension pneumothorax” is a pocket of air that keeps expanding and building pressure as air gets in and can’t get out, which can compromise breathing and circulation and become fatal. A “simple pneumothorax” is a small pocket of air that is not expanding and shows up on x-ray. Look for asymmetrical pain upon respiration, progressively worsening dyspnea, jugular veinous distension, movement of the patient’s trachea away from baseline, and unequal breath sounds. Be highly suspicious of spontaneous pneumothorax in patients with Marfan’s Syndrome.

P – Pulmonary Embolism: This is a blockage, usually a blood clot, in a pulmonary blood vessel. This can keep the lungs from performing properly and cause both hypoxia and hypercarbia by blocking blood from being able to exchange gasses. Look for sharp chest pain that worsens with respiration usually on one side of the chest lateral from the sternum. Clots generated in a deep venous thrombosis (DVT) that break off and become lodged in the lung are common causes of Pulmonary Emboli and providers should obtain a history checking to see if the patient has recently been immobile. (for more on PE’s, check out Wikipedia’s great post on the topic)

A – Aneurysm: In this case we’re referring to a thoracic aortic aneurysm and/or aortic dissection. These can be caused by a separation of the tunica intima (inner lining of the artery) from the tunica media (middle lining of the artery) or the Tunica Externa (outer lining). These are common in patients with Marfan’s syndrome but can be found in other patients as well, sometimes precipitated by trauma. Look for patients complaining of a “ripping” or “tearing” sensation. Also check for pulsus paradoxus and a difference in systolic blood pressure between the arms.

PAPPA is a great mnemonic tool for paramedics and EMTs to use to help catch the High-Risk/Can’t Miss conditions that might be the cause of your patient’s chest pain. Assess these patients very well and document your findings in depth. Patients experiencing chest pain should be transported to the hospital in all cases and any against-medical-advice refusals should be exhaustively documented as these conditions can be lethal if left untreated. Never assume chest pain is “just indigestion” or you may end up in one of my posts, like these medics did in this case study.

Thanks to CME4Life for giving me the idea for this post. Also, here’s a video with John Bielinski explaining PAPPA for emergency physicians: