O objetivo deste estudo foi avaliar o uso da cintilografia de perfusão miocárdica planar de repouso para o diagnóstico de insuficiência coronariana aguda em pacientes com dor torácica e eletrocardiograma sem alterações sugestivas de isquemia. Foram estudados 71 pacientes com idades entre 34 e 87 (média 58, desvio-padrão 12) anos; 44 (62%) eram do sexo masculino e 27 (38%) do feminino. Os pacientes com dor torácica foram avaliados na unidade de emergência com anamnese, exame físico e eletrocardroqrarna de 12 derivações. Pacientes com dor torácica de duração superior a 20 minutos, em vigência da dor ou sem dor, mas que sofreram dor torácica até seis horas anies do atendimento e com eletrocardioqrarna sem alterações sugestivas de isquemia miocárdica, foram submetidos à cintilografia planar de perfusão miocárdica de repouso quando solicitada pelo médico assistente. O tempo médio entre o início da dor toràcica e a Injeção do radiotraçador foi de três horas e seis minutos. Treze pacientes apresentavam dor torácica no momento da injeção. Foram colhidas amostras sanguineas para dosagens de atividade da creatinoquinase-MB (CK-MB), CK-MB massa, troponina I e mioglobina, seis horas após o início da dor torácica. O diagnóstico de insuficiência coronariana aguda foi feito em pacientes com angina de repouso, infarto agudo do miocárdio, pacientes submetidos à revascularização miocárdica, presença de lesões coronarianas significativas na angiografia (>- 70% estenose em artérias coronárias ou seus ramos ou .- 50% em tronco de artéria coronária esquerda) realizada durante a inernação e morte cardíaca foram considerados eventos cardíacos maiores. As cintilografias com defeito de captação foram consideradas sugestivas de isquemia miocárdica e foram comparadas com o diagnóstico clínico e com a ocorrência de eventos cardíacos maiores até três meses após a alta.Pacientes sem insuficiência coronariana aguda, dispensados da unidade de emergência, foram encaminhados para realização ambulatorial de cintilografia de perfusão miocárdica tomográfica de esforço ou com dipiridamol. Vinte e um pacientes (29,6%) tiveram o diagnóstico de insuficiência coronariana aguda e em 15 (21,1%) ocorreram eventos cardíacos maiores (oito com infarto agudo do miocárdio e sete foram submetidos à revascularização miocárdica). A cintilografia planar de perfusão miocárdica demonstrou defeitos de captação em 21 (29,6%) pacientes, dos quais 16 (76,2%) tiveram o diagnóstico de insuficiência coronariana aguda, 12 (80%) apresentaram eventos cardíacos maiores e 7 (87,5%) infarto agudo do miocárdio. O valor preditivo negativo da cintilografia planar de perfusão miocárdica foi de 90% para o diagnóstico de insuficiência coronariana aguda e de 94% para detecção de eventos cardíacos maiores. Portanto a cintilografia planar de perfusão miocárdica foi eficaz para o diagnóstico de insuficiência coronariana aguda em pacientes com dor torácica e electrocardiograma sem alterações sugestivas de isquemia / The objective of the study was to evaluate the usefulness of rest scintigraphic planar myocardial perfusion imaging in patients with acute chest pain suspected of myocardial ischemia and nondiagnostic ECG in the diagnosis of acute coronary syndromes and to predict adverse cardiac outcomes. Patients within 6 hours of chest pain onset and nondiagnostic ECGs underwent planar myocardial perfusion imaging with Technetium-99m sestamibi and measurements of serum creatine kinase-MB, creatine kinase-MB mass. troponin and myoglobin 6 hours after the onset of symptoms. Studies showing perfusion defects were considered suggestive of acute coronary syndromes and were compared to the diagnosis made by the attending cardiologist. Clinical diagnosis of acute coronary syndromes was made In patients with rest angina admitted to the hospital, acute myocardial Infarction, myocardial revascularization, demonstration of significant coronary artery disease on angiography or cardiac death. Acute myocardial revascularization and cardiac death were considered major cardiac events. Patients discharged without acute coronary syndromes were scheduled for outpatient stress myocardial perfusion imaging. A total of 71 patients underwent planar myocardial perfusion imaging. The mean age was 58 +- 12 years, 44 (62%) were male and 27 (38%) female. The mean time between chest pain onset and radiotracer injection was 3 hours and 6 minutes, thirteen patients had chest pain at the moment of iniection. Twenty-one (29,6%) patients had acute coronary syndromes, 15 (21,1 %) had major cardiac events (8 myocardial infarction and 7 underwent myocardial revascularization). Planar perfusion imaging demonstrated perfusion defects in 21 patients, 16 (76,2%) patients with acute coronary syndromes, 12 (80%) patients who had major cardiac events and in 7 (87,5%) patients with myocardial infarction. The negative predictive value of planar perfusion image was 90% for diagnosis of acute coronary syndromes and 94% for detecting major cardiac events. In conclusion, early planar perfusion imaging allowed for a rapid and accurate risk stratification of emergency departments patients with possible myocardial ischemia and nondiagnostic ECGs

<p>Aim: The aim of this study was to investigate how VAS (Visual Analogue Scale) is used in the prehospital environment, and describe how patients 40 years and older with acute chest pain describe their pain with help of VAS. Further, to investigate how the literature describes other instruments to evaluate pain. Method: This was a descriptive study and used both literature and empiric material as foundation. The selection consist of the paramedics medical record from one emergency department, 100 men and 100 women with chest pain witch had been transported with ambulance to one hospital in middle of Sweden. A literature review was done in order to see what previous research recommends for pain rating scales.</p><p>Results: The study showed that 71 (35 %) of 200 individuals pain were rated with VAS according to the guidelines for the ambulance department. The entire selection rated the pain on VAS between 1-10. The group 40-65 years rated their pain relatively high on VAS (3-10), in relation to the group 66-91 years (1-10). The literature does not advocate any special pain rating instrument, but recommend ARS, VRS, NRS and VAS as measures in the prehospital environment.</p> / <p>Syfte: Syftet med studien var att undersöka i vilken omfattning Visuell Analog Skala (VAS) används inom ambulanssjukvården, beskriva hur patienter 40 år och äldre med akuta centrala bröstsmärtor skattar smärtans intensitet med hjälp av VAS. Vidare var syftet att undersöka hur litteraturen beskriver olika instrument för att skatta smärta inom ambulanssjukvården. Metod: Studien har genomförts som en deskriptiv studie och nyttjat både litteratur och empiriskt material som underlag. Urvalet bestod av ambulansjournaler från en ambulansstation, 100 män och 100 kvinnor som transporterats med ambulans till ett sjukhus i Mellansverige på grund av central bröstsmärta. En litteratur genomgång gjordes för att se vad tidigare forskning rekommenderar för smärtskattningsinstrument. Huvudresultat: Studien visade att 71 (35 %) av 200 individer var smärtskattade med hjälp av VAS, enligt riktlinjerna för ambulansen. Hela urvalet skattade smärtan på VAS skalan mellan 1-10. I åldersgruppen 40-65 år skattar de sin smärta relativt högt på VAS skalan (3-10) i förhållande till åldersgruppen 66-91 år (1-10). Litteraturen talar inte entydigt för något speciellt smärtskattnings instrument, men talar för att använda ARS, VRS, NRS och VAS i den prehospitala verksamheten</p>

<p>Abstract</p><p>Kerstin Forslund (2007): Challenges in prehospital emergency care – patient, spouse and personnel perspectives. Örebro Studies in Caring Sciences 16. 75 pp.</p><p>Prehospital emergency care (PEC) with the emergency call to the Emergency Medical Dispatch (EMD) centre is an essential part of the health-care system. It is important to obtain knowledge about the links in the PEC chain from the perspectives of those providing the service and those receiving it. The overall aim of this thesis was to describe the challenges surrounding PEC based on the experiences of patients, spouses and personnel. A qualitative descriptive design was used in the five papers included. The data analysis methods were phenomenological-hermeneutics (I–III), qualitative content analysis (IV–V) and descriptive statistics (V).</p><p>Interviews with thirteen patients who had called the EMD-centre due to acute chest pain (I) revealed a general satisfaction with PEC. They were aware of the number to call in an emergency but were uncertain when to call. The potentially life threatening emergency situation was marked by vulnerability and dependency and was fraught with pain, fear and a sense of aloneness.</p><p>An overall theme of aloneness emerged from the interviews with nineteen spouses who had placed an emergency call for their husband or wife that was experiencing acute chest pain (II). The challenges in being a spouse to a person in need of PEC were associated with: “Being responsible and trying to preserve life” and “Being able to manage the uneasiness and feel trust in an uncertain situation”. The spouses were in an escalating spiral of aloneness, worry, uncertainty, stress, fear of loss and desperation.</p><p>Interviews with sixteen emergency operators dealt with situations they considered difficult to deal with and their reflections on how they managed such situations (III). Uncertainty, communication difficulties and insufficient resources characterized those situations. Skills, knowledge, experience, as well as personal qualities such as sensitivity, self-insight, empathy and intuition were regarded as important when handling them.</p><p>Interviews with four nurses and fifteen emergency operators related to their experiences of working together for two years at an EMD-centre were conducted after the nurses were added to the EMD-centre to increase medical and nursing competence (IV). Initial frustration and scepticism changed to positive experiences with improved cooperation and service. The nurses voiced difficulties dealing with the more medically urgent calls and the emergency operators with the more complicated and diffuse medical cases.</p><p>A total of 336 questionnaires related to alarms involving acute chest pain and given the highest priority by the emergency operator were collected in a study aimed at describing the ambulance personnel’s perceptions of the quality of the information received from the EMD-centre (V). The ambulance personnel perceived most of the information such as patient assessment, condition, history, preparedness and in particular pain status to be of high quality.</p><p>In summary: In PEC there is many interdependent complexities that present demands and challenges to the actors involved (I–V). In general those who received emergency assistance from PEC were satisfied, but the margins between success and failure are small. Risks for errors exist throughout the PEC chain and time poses a challenge. Understanding is crucial for all involved, and the same situation can be experienced differently. Challenges inherent in PEC are the communication problems, unpredictability and uniqueness along with daring to be in the acute situation and dealing with a sense of aloneness, uncertainty and dependency. The personnel that do not have the ability to see the person they are helping are even more challenged. Important attributes for PEC personnel are caring attitudes, personal skills, experiences and professional knowledge. PEC personnel have the authority and power to act and make decisions, in which responsibility, sensitivity, and human dignity must be addressed. Lives are saved with PEC despite all the challenges and possibilities for error, such as those that exist between the different actors. It is vital that the PEC chain is as strong as possible.</p><p>Keywords: challenge, prehospital, emergency, care, patient, spouse, personnel,</p><p>chain, acute chest pain.</p>

Syftet med denna kvalitativa intervjustudie var att belysa vad sjuksköterskor på ambulansen respektive akutmottagningen ansåg vara viktig information till patienter med akuta bröstsmärtor samt vad som var viktigt att tänka på vid informering av dem. Tio intervjuer med sjuksköterskor utfördes, fem på ambulansen samt fem på akutmottagningen. Resultatet har delats upp utifrån de olika arbetsplatserna. Resultatet visade att det fanns stora likheter i hur sjuksköterskorna svarade på frågorna som ställts. Det som ansågs viktigt att ge information om var vad som skedde och varför, det var även viktigt att informera om läkemedel och dess biverkningar och att med den information de gav, lugna patienterna. En stor punkt som kom upp från båda arbetsplatserna var att det var viktigt att informera om det som patienten frågade efter. På ambulansen ansåg sjuksköterskorna även att det var viktigt att försöka hålla informationen till det som var viktigt och relevant för patienten. Sjuksköterskorna på akutmottagningen ansåg att det var viktigt att informera så mycket som möjligt och att hålla patienten uppdaterad. / The aim of this qualitative interview study was to elucidate what nurses at ambulance and emergency department thought was important information to give to patients with acute chest pain and what was important to think about when informing them. Ten interviews with nurses was performed, five at the ambulance and five at the emergency department. The result has been divided between the two workplaces. The study showed that there where large similarities in how the nurses responded to the questions asked. The objects that was thought of as important was to give information about what happened and why, it was also important to give information about pharmaceuticals and it´s side effects and with the information that they gave, try to calm the patients down. A large item that came up was that it was important to inform about what the patients asked for. At the ambulance the nurses also thought that it was important to try to keep the information to what was important and relevant to the patient. The nurses at the emergency department thought that it was important to inform as much as possible and keep the patient updated.

Aim: The aim of this study was to investigate how VAS (Visual Analogue Scale) is used in the prehospital environment, and describe how patients 40 years and older with acute chest pain describe their pain with help of VAS. Further, to investigate how the literature describes other instruments to evaluate pain. Method: This was a descriptive study and used both literature and empiric material as foundation. The selection consist of the paramedics medical record from one emergency department, 100 men and 100 women with chest pain witch had been transported with ambulance to one hospital in middle of Sweden. A literature review was done in order to see what previous research recommends for pain rating scales. Results: The study showed that 71 (35 %) of 200 individuals pain were rated with VAS according to the guidelines for the ambulance department. The entire selection rated the pain on VAS between 1-10. The group 40-65 years rated their pain relatively high on VAS (3-10), in relation to the group 66-91 years (1-10). The literature does not advocate any special pain rating instrument, but recommend ARS, VRS, NRS and VAS as measures in the prehospital environment. / Syfte: Syftet med studien var att undersöka i vilken omfattning Visuell Analog Skala (VAS) används inom ambulanssjukvården, beskriva hur patienter 40 år och äldre med akuta centrala bröstsmärtor skattar smärtans intensitet med hjälp av VAS. Vidare var syftet att undersöka hur litteraturen beskriver olika instrument för att skatta smärta inom ambulanssjukvården. Metod: Studien har genomförts som en deskriptiv studie och nyttjat både litteratur och empiriskt material som underlag. Urvalet bestod av ambulansjournaler från en ambulansstation, 100 män och 100 kvinnor som transporterats med ambulans till ett sjukhus i Mellansverige på grund av central bröstsmärta. En litteratur genomgång gjordes för att se vad tidigare forskning rekommenderar för smärtskattningsinstrument. Huvudresultat: Studien visade att 71 (35 %) av 200 individer var smärtskattade med hjälp av VAS, enligt riktlinjerna för ambulansen. Hela urvalet skattade smärtan på VAS skalan mellan 1-10. I åldersgruppen 40-65 år skattar de sin smärta relativt högt på VAS skalan (3-10) i förhållande till åldersgruppen 66-91 år (1-10). Litteraturen talar inte entydigt för något speciellt smärtskattnings instrument, men talar för att använda ARS, VRS, NRS och VAS i den prehospitala verksamheten

Background and aims. In patients consulting for chest pain, it is of great importance to evaluate the possibility of ischemic heart disease (IHD). The aims in this thesis were to investigate the accuracy of the general practitioners’ clinical assessments and the applicability of exercise testing and myocardial perfusion scintigraphy (MPS) in patients consulting for chest pain in primary care. Statins are known to prevent IHD. A further aim was therefore to investigate if a relation could be detected on a population basis between the use of statins and the morbidity of acute myocardial infarction (AMI). Methods. All patients from 20 to 79 years, consulting for a new episode of chest pain in three primary health care centres, were included during almost two years from 1998 to 2000. The patients were managed according to the clinical evaluation. The presence of IHD was excluded either by clinical examination only, or if stable IHD was in question, by exercise testing and if the exercise test was inconclusive by an additional MPS. If unstable IHD or myocardial infarction was suspected, referral for emergency hospital examination was made. Correlations between statin sales and the morbidity of AMI in Sweden’s municipalities were analysed in an ecological, register based study. Adjustment was made for sales of antidiabetics, socio-economic deprivation indexes and geographic coordinates. Results. Consultations for chest pain represented 1.5% of all consultations in the ages 20 to 79 and were made by 554 patients. In 281 patients IHD was excluded by clinical examination only. In 208 patients stable IHD and in 65 unstable IHD was in question. Four patients (1.4%) evaluated as not having IHD, were diagnosed with angina pectoris or AMI within three months. Exercise testing was performed in 191 patients and revealed no IHD in 134 and IHD in 14 patients. In 43 patients the exercise test results were equivocal. Thirty-nine of these patients underwent MPS, which showed no IHD in 20 and IHD in 19 of the patients. In a follow up almost six years later, neither mortality rate nor prevalence of IHD differed significantly between the 384 study patients evaluated not to have IHD and the population controls. Statin sales and AMI-incidence or mortality showed no strong associations from 1998 to 2002. Conclusions. ·Primary care is an appropriate level of care for ruling out IHD as the cause of chest pain, with sufficient safety and for diagnostics of stable IHD. ·Exercise testing and myocardial perfusion scintigraphy are useful procedures when investigating chest pain patients in primary care. ·The results indicate that preventive measures other than increased statin treatment should be considered to further decrease AMI-morbidity.

Hjärt-kärlsjukdomar är den vanligaste dödsorsaken i Sverige. 41 % av kvinnorna och 39% av männen avled till följd av hjärt-kärlsjukdomar år 2011. Då ambulanspersonalen ofta har begränsad tid på sig att etablera kontakt och skapa sig en helhetsbild över patientens tillstånd, vilket är viktigt för att säkerställa en god behandling, kan kravet på effektivitet bli en stressfaktor. För att minska stressen kan det vara bra att utgå från en strukturerad bedömning av patientens tillstånd och där en god anamnes är ett viktigt redskap. Det finns utarbetade instrument för detta,däribland anamnestagande enligt Advanced Medical Life Support®-konceptet(AMLS). Detta är ett koncept som bygger på bedömning av patientens tillstånd och sjukdomshistoria. Syftet: Att undersöka i vilken utsträckning sjuksköterskorna i det aktuella landstinget uppger att de enligt AMLS-modellen® bedömer patienter med akut bröstsmärta samt om bedömningen dokumenteras och vilken betydelse sjuksköterskorna ger bedömningen och dokumentationen. Metod: Studien genomfördes som e nkvantitativ enkätbaserad tvärsnittstudie. Enkäter skickades ut under två veckor till tre ambulansstationer i det aktuella länet, den insamlade datan analyserades med hjälp av analytisk och deskripitv data. Resultat: Majoriteten av de sjuksköterskor som deltog i studien uppgav att de följde riktlinjern aenligt AMLS®-konceptet. En majoritet  av sjuksköterskorna i studien uppgav även att de dokumenterade sina bedömningar av patienternas svar. Majoriteten av sjuksköterskorna i studien  ansåg att det var betydelsefullt att dokumentera båda patientens svar. Dock fanns det en del motsägendesfulla resultat, att sjuksköterskan uppgav att det var viktigt att bedöma elle rdokumentera, men sedan inte gjorde det. Slutsats:Då studien är begränsad både i storlek samt svarsfrekvens går det inte att dra några definitiva slutsatser. Majoriteten av de sjuksköterskor som deltog i studien uppgav att de följde riktlinjerna enligt AMLS®-konceptet. Majoriteten av sjuksköterskorna uppgav att de dokumenterade sina bedömningar av patienternas svar. / Cardiovascular disease is the leading cause of death in Sweden. 41 % of the women and 39 % of the men died as a result of cardiovascular diseases, in the year 2011. The ambulance staffs often have limited time to connect and form and create a comprehensive picture of the patient’s condition, which is crucial for ensuring good treatment. The requirement for efficiency can become a stress factor. To reduce the stress you may want to start with a structured assessment of the patient's condition, a good anamnesis is important. There are elaborate instruments for this, including gaining a proper anamnesis  using the Advanced Medical Life Support ® concept. (AMLS). This is an American concept based on the assessment of the patient's condition and medical history. Aim: To examine the extent to which nurses in the current County Council state that they assesses patients with acute chest pain, according to the AMLS model ® and if the assessment is documented and the importance nurses gives assessment and documentation. Method: The study was conducted through a quantitative survey-based cross-sectional study. Questionnaires were sent out for two weeks to three ambulance stations in the county, the gathered data were analyzed using analytical and descriptive data. Results: The majority of nurses reported that they followed the guidelines of the AMLS ® concept. The majority of nurses reported that they document their patient's response. The majority of nurses felt it was important to document. Some inconsistent results were however present, the nurse said it was important to document but did not. Conclusion: This study is limited in both size and response rate, it is not possible to draw any definitive conclusions. The majority of the nurses who participated in the study stated that they followed the guidelines of the AMLS ® concept. The majority of the nurses reported that they documented their assessment of patients' responses.

Prehospital emergency care (PEC) with the emergency call to the Emergency Medical Dispatch (EMD) centre is an essential part of the health-care system. It is important to obtain knowledge about the links in the PEC chain from the perspectives of those providing the service and those receiving it. The overall aim of this thesis was to describe the challenges surrounding PEC based on the experiences of patients, spouses and personnel. A qualitative descriptive design was used in the five papers included. The data analysis methods were phenomenological-hermeneutics (I–III), qualitative content analysis (IV–V) and descriptive statistics (V). Interviews with thirteen patients who had called the EMD-centre due to acute chest pain (I) revealed a general satisfaction with PEC. They were aware of the number to call in an emergency but were uncertain when to call. The potentially life threatening emergency situation was marked by vulnerability and dependency and was fraught with pain, fear and a sense of aloneness. An overall theme of aloneness emerged from the interviews with nineteen spouses who had placed an emergency call for their husband or wife that was experiencing acute chest pain (II). The challenges in being a spouse to a person in need of PEC were associated with: “Being responsible and trying to preserve life” and “Being able to manage the uneasiness and feel trust in an uncertain situation”. The spouses were in an escalating spiral of aloneness, worry, uncertainty, stress, fear of loss and desperation. Interviews with sixteen emergency operators dealt with situations they considered difficult to deal with and their reflections on how they managed such situations (III). Uncertainty, communication difficulties and insufficient resources characterized those situations. Skills, knowledge, experience, as well as personal qualities such as sensitivity, self-insight, empathy and intuition were regarded as important when handling them. Interviews with four nurses and fifteen emergency operators related to their experiences of working together for two years at an EMD-centre were conducted after the nurses were added to the EMD-centre to increase medical and nursing competence (IV). Initial frustration and scepticism changed to positive experiences with improved cooperation and service. The nurses voiced difficulties dealing with the more medically urgent calls and the emergency operators with the more complicated and diffuse medical cases. A total of 336 questionnaires related to alarms involving acute chest pain and given the highest priority by the emergency operator were collected in a study aimed at describing the ambulance personnel’s perceptions of the quality of the information received from the EMD-centre (V). The ambulance personnel perceived most of the information such as patient assessment, condition, history, preparedness and in particular pain status to be of high quality. In summary: In PEC there is many interdependent complexities that present demands and challenges to the actors involved (I–V). In general those who received emergency assistance from PEC were satisfied, but the margins between success and failure are small. Risks for errors exist throughout the PEC chain and time poses a challenge. Understanding is crucial for all involved, and the same situation can be experienced differently. Challenges inherent in PEC are the communication problems, unpredictability and uniqueness along with daring to be in the acute situation and dealing with a sense of aloneness, uncertainty and dependency. The personnel that do not have the ability to see the person they are helping are even more challenged. Important attributes for PEC personnel are caring attitudes, personal skills, experiences and professional knowledge. PEC personnel have the authority and power to act and make decisions, in which responsibility, sensitivity, and human dignity must be addressed. Lives are saved with PEC despite all the challenges and possibilities for error, such as those that exist between the different actors. It is vital that the PEC chain is as strong as possible.

Chest pain is an extremely common presenting symptom that is usually related to a cardiac cause. This case illustrates an unusual presentation of multiple myeloma as a cause of atypical chest pain. This case presentation shows the importance of having a broad differential diagnosis while evaluating patients with atypical chest pain. It also illustrates the potential role of Tc-99m sestamibi imaging as a diagnostic modality in patients with multiple myeloma.

No description available.