title: Chest Pain of Suspected Cardiac Origin: Current Evidence-based Recommendations for Prehospital Care.
abstract: BACKGROUND
  In the United States, emergency medical services (EMS) protocols vary widely across jurisdictions. We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of chest pain of suspected cardiac origin and to compare these recommendations against the current protocols used by the 33 EMS agencies in the state of California.
  
  
  METHODS
  We performed a literature review of the current evidence in the prehospital treatment of chest pain and augmented this review with guidelines from various national and international societies to create our evidence-based recommendations. We then compared the chest pain protocols of each of the 33 EMS agencies for consistency with these recommendations. The specific protocol components that we analyzed were use of supplemental oxygen, aspirin, nitrates, opiates, 12-lead electrocardiogram (ECG), ST segment elevation myocardial infarction (STEMI) regionalization systems, prehospital fibrinolysis and β-blockers.
  
  
  RESULTS
  The protocols varied widely in terms of medication and dosing choices, as well as listed contraindications to treatments. Every agency uses oxygen with 54% recommending titrated dosing. All agencies use aspirin (64% recommending 325 mg, 24% recommending 162 mg and 15% recommending either), as well as nitroglycerin and opiates (58% choosing morphine). Prehospital 12-Lead ECGs are used in 97% of agencies, and all but one agency has some form of regionalized care for their STEMI patients. No agency is currently employing prehospital fibrinolysis or β-blocker use.
  
  
  CONCLUSIONS
  Protocols for chest pain of suspected cardiac origin vary widely across California. The evidence-based recommendations that we present for the prehospital diagnosis and treatment of this condition may be useful for EMS medical directors tasked with creating and revising these protocols.
authors.affiliation: University of California, San Francisco, Department of Emergency Medicine, San Francisco, California.
authors.forename: P Brian
authors.initials: PB
authors.lastname: Savino
authors.affiliation: EMS Medical Directors Association of California, California.
authors.forename: Karl A
authors.initials: KA
authors.lastname: Sporer
authors.affiliation: EMS Medical Directors Association of California, California.
authors.forename: Joe A
authors.initials: JA
authors.lastname: Barger
authors.affiliation: EMS Medical Directors Association of California, California.
authors.forename: John F
authors.initials: JF
authors.lastname: Brown
authors.affiliation: EMS Medical Directors Association of California, California.
authors.forename: Gregory H
authors.initials: GH
authors.lastname: Gilbert
authors.affiliation: EMS Medical Directors Association of California, California; University of California, Irvine, Center for Disaster Medical Sciences, Orange, California.
authors.forename: Kristi L
authors.initials: KL
authors.lastname: Koenig
authors.affiliation: EMS Medical Directors Association of California, California.
authors.forename: Eric M
authors.initials: EM
authors.lastname: Rudnick
authors.affiliation: EMS Medical Directors Association of California, California.
authors.forename: Angelo A
authors.initials: AA
authors.lastname: Salvucci
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D000701:Analgesics, Opioid / Q000627:therapeutic use; D000787:Angina Pectoris / Q000175:diagnosis / Q000628:therapy*; D001241:Aspirin / Q000627:therapeutic use; D002140:California; D002985:Clinical Protocols; D004562:Electrocardiography / Q000706:statistics & numerical data; D004632:Emergency Medical Services / Q000379:methods* / Q000706:statistics & numerical data; D055317:Evidence-Based Practice; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006291:Health Policy; D006801:Humans; D009020:Morphine / Q000627:therapeutic use; D005996:Nitroglycerin / Q000627:therapeutic use; D010100:Oxygen / Q000627:therapeutic use; D017410:Practice Guidelines as Topic; D014481:United States; D014665:Vasodilator Agents / Q000627:therapeutic use
chemical_list: D000319:Adrenergic beta-Antagonists; D000701:Analgesics, Opioid; D005343:Fibrinolytic Agents; D014665:Vasodilator Agents; D009020:Morphine; D005996:Nitroglycerin; D001241:Aspirin; D010100:Oxygen