Chest Pain PDF

Chest pain Objective Approach patients with chest pain in the ED - Be able to list potential life-threatening causes of chest - Patients...

Chest pain Objective Approach patients with chest pain in the ED - Be able to list potential life-threatening causes of chest - Patients attending the ED with chest pain present a classic pain: ACS, aortic dissection, PE, tension Pneumothorax. diagnostic challenge. - List the key features in history and physical examination - A minority will have a potentially life-threatening condition - Describe the general, immediate actions and interventions. and need to immediate intervention. - Recognize the typical and atypical presentations of ACS. - A significant minority will have benign pathology or no - Be familiar with the life-threatening pattern of ECGs. significant cause identifiable, reassured and discharged. - Describe the initial interventions, diagnostic testing, and - The rest will have a specific identifiable cause for their pain management priorities. that will require a diagnosis and treatment plan. - A logical and systematic approach to patients will achieve a Introduction diagnosis in the vast majority of cases. - A focused history and physical examination supported by - Approximately 6 million patients visit the emergency an ECG and chest x-ray will allow a firm diagnosis. department (ED) each year with complaints of chest pain. - Chest pain is a symptom a broad differential diagnosis. - Emergency physicians: è Responsible for robustly identifying and treating a Patients who present with a Hx of ischemic significant minority of patients with serious pathologies. chest pain who have a normal examination, ECG and CXR will require further risk è Avoiding unnecessary investigation and admission for stratification in order to allow safe discharge the majority of patients who can be safely discharged. from the emergency department. Such a Table 1: The spectrum of pathology presenting with chest pain rule-out strategy will involve the use of cardiac markers (troponin) and possible System Life-threatening Urgent Non-urgent exercise testing. Clinical pathways which Acute myocardial infarction Unstable angina Stable angina combine clinician gestalt with the admission Coronary vasospasm Cardiovascular Aortic dissection Pericarditis Valvular heart disease ECG and subsequent troponin assay(s) have Pulmonary embolism Hypertrophic cardiomyopathy Myocarditis shown a 100% sensitivity Viral pleurisy Pulmonary Tension pneumothorax Simple pneumothorax Pneumonia Costochondritis Musculoskeletal Chest wall injury Cholecystitis Oesophageal reflux Gastrointestinal Oesophageal rupture Pancreatitis Biliary colic Peptic ulcer Postherpuetic neuralgia Herpes zoster Other Mediastinitis Malignancy Psychological/anxiety  Chest pain - History è Identify the risk factors è It’s very important to identify life-threatening conditions Condition Risk factors è Description of the pain is the first step in diagnosis. Acute coronary syndrome Previous known CAD (previous MI, angioplasty, etc). P Character of the pain Positive family history. Advanced age, male gender. P The location DM, HTN, hypercholesterolemia. P Severity Smoker, obesity, sedentary lifestyle. Aspirin usage. P Radiation of the pain Aortic dissection Chronic hypertension. Inherited CTD e.g. Marfans, Ehlers-Danlos. P Onset and duration of the pain Bicuspid aortic valve. Coarctation of the aorta. P Relieving and aggravating factors Atherosclerosis. Giant Cell Arteritis. P Associated symptoms. Iatrogenic related to cardiac catheterization. P Previous episodes and relevant past medical history. Pregnancy. Cocaine use. Pulmonary embolism Previous Hx of VTE. Condition Description Pregnancy particularly 6-weeks post-partum Ischemic cardiac pain Retrosternal pressure, tightness, constricting. +ve family Hx of VTE (2 or more family members). Radiation to neck, jaw, shoulder, arms. Recent prolonged immobilization (> 3 days). Ischemic cardiac pain Major surgery within previous 12 weeks. Crescendo in nature, related to exertion. Fracture of lower limb within previous 12 weeks. Associated: diaphoresis, sweating, nausea, pallor. Active cancer (within previous 6 months, recent Pericarditis Atypical, retrosternal, sometimes pleuritic. treatment, palliation). Positional relieved on sitting forward. Lower extremity paralysis. Gastro-esophageal Retrosternal, burning. Tension pneumothorax Severe SOB. Tension pneumothorax Associated with ingestion. Shallow breathing. Acute chest pain. Aortic dissection Tearing pain, sudden in onset, worst ever pain, Tachycardia, Hypotension and Hypoxia Radiation to back. Altered mental status. Pulmonary embolism Atypical, may be pleuritic. Associated with SOB, occasional hemoptysis. Pneumothorax Pleuritic, sharp, positional, sudden in onset. - Physical examination Associated with breathlessness. è Physical findings associated with ACS are non-specific. Pneumonia Atypical, may be pleuritic. è Sometimes the signs strength your suspicion Associated with cough, sputum, fever. P S3, hypotension, crepitations à AMI. Musckoloskeletal Sharp, positional, pleuritic. P Fever, signs of pulmonary collapse à consolidation. Aggravated movement, deep inspire. & coughing. P Tachypnea, tachycardia, unilateral diminished air entry and breath sounds à pneumothorax.  Chest pain Condition Physical Findings P ST segment elevation is associated with the highest ACS Diaphoresis, tachycardia, tachypnea, pallor. likelihood of AMI followed, by new Q waves, new Complications of AMI Hypotension, S3, pulmonary crepitations. conduction deficit (LBBB), ST depression, T wave changes # JVP, bradycardia, new murmur. Aortic dissection Diaphoresis, hypotension, HTN, tachycardia. Condition ECG finding Asymmetrical upper limb BP (> 20 mmHg), new Classic MI ST segment elevation (>1mm) in contiguous leads. murmur (aortic regurgitation), wide pulse pressure. New LBBB. Q wave > 0.04-sec duration. Focal neurological findings. Subendocardial infarction T wave inversion or ST segment depression. Pulmonary embolism Acute respiratory distress, diaphoresis, hypotension, Unstable angina Most often normal or nonspecific changes. tachycardia, hypoxemia, # JVP, pleural rub. May see T wave inversion. Pneumonia Fever, signs of pulmonary collaps/consolidation, Pericarditis Diffuse concave-upward ST segment elevation. tachycardia, tachypnea. PR segment depression (specific). Esophageal rupture Diaphoresis, hypotension, tachycardia, fever, Pulmonary embolus Sinus tachycardia (MC). Hammans sign, subcutaneous emphysema, epigastric RBBB with/without strain. S1Q3T3. tenderness. Myocarditis Diffuse ST/T wave changes. Simple pneumothorax Tachypnoea, tachycardia, unilateral diminished air entry and breath sounds, subcutaneous emphysema. è Chest X-ray (CXR): Tension pneumothorax Tachypnoea, hypotension, tachycardia, hypoxemia/ P CXR is the next investigation commonly performed in the ED. # JVP, unilateral diminished air entry and breath sound, subcutaneous emphysema, tracheal deviation. P CXR is particularly useful with non-cardiac chest pain. Pericarditis Tachycardia, fever, pericardial rub. P Can definitively confirm a diagnosis suspected on Myocarditis Hypotension, tachycardia, fever clinical grounds (pneumothorax or pneumonia). S3, pulmonary crepitations, displaced apex beat. P Normal CXR will also be helpful in making a diagnosis Mediastinitis Tachycardia, fever, Hammans sign, subcutaneous by excluding other potential causes. emphysema, hypotension. Cholecystitis Diaphoresis, fever, tachycardia, right upper quadrant tenderness. Hamman’s sign: audible systolic noise on cardiac auscultation - Investigations è ECG: P The most commonly and rapidly performed investigation for a patient with chest pain P A normal ECG in a patient with chest pain does not allow safe discharge without further investigation.  Chest pain Condition Radiographic Finding Ischemic heart disease Acute coronary syndrome No specific radiographic finding. Aortic dissection Mediastinal widening. - History Abnormal aortic contour. è Anginal pain Globular heart shadow (hemopericardium). § A constricting discomfort in the front of the Pleural effusion (hemothorax). chest, or in the neck, shoulders, jaw, arms. Pneumothorax Absence of pulmonary vascular markings § Precipitated by physical exertion. Tension pneumothorax Absence of pulmonary vascular markings. Mediastinal displacement. § Relieved by rest or GTN within 5 minutes. Pneumonia Localized or diffuse pulmonary infiltration. è Atypical chest pain if only two out of three. Localized pulmonary atelectasis/consolidation. è Non-angina chest pain if one or none of these exist. Pulmonary embolism Normal chest radiograph è No single factor in Hx alone can rule in or rule out AMI. Esophageal rupture Pneumomediastinum. Mediastinitis Pneumomediastinum Classification of IHD according to: Pain characteristics: stable vs ACS Myocarditis Enlarged cardiac shadow. Cardiac enzymes: unstable vs MI Pericarditis Globular heart shadow. ECG: NSTMI vs STMI - Management è Patients with critical diagnoses generally are admitted to the intensive care unit. è Patients with emergent diagnoses typically are admitted to the hospital. - Management (immediate interventions): è Airway, breathing, and circulation assessed è Patients with non-emergent diagnoses are usually è Preliminary Hx and examination obtained. treated as outpatients. è 12-lead electrocardiogram (ECG) è è Resuscitation equipment brought to bedside è Cardiac monitor & O2 given as necessary è IV access and blood work obtained è Aspirin 162 to 325 mg given è Nitrates given (unless contraindicated) è B-blockers if no contraindications è If STEMI: urgent PCI within 90 min è If more than 90 min, thrombolytic therapy  Chest pain Aortic dissection - Predisposing factors è Hypertension (most common) - Definition: tear in the aortic intima with subsequent è CTD: Marfan, syndrome Ehlers-Danlos syndrome separation of the tissue within the weakened media. è Bicuspid aortic valve, Coarctation of the aorta - The dissection is followed by anterograde or retrograde è Turners Syndrome flow of blood within the outer third of the tunica media. è Pregnancy - Dissection is NOT aneurysmal (different diseases). - Pathophysiological consequences of AAD - Classification è Rupture into various body cavities: è Stanford: P Type A: ascending aorta and/or the arch of aorta Ascending aorta Hemopericardium (syncope and /or sudden death) Right hemothorax (invariably sudden death). P Type B: descending aorta (distal left subclavian artery) Arch of aorta Mediastinal hematoma. Interatrial septal hematoma (conduction defects) è DeBakeys: Compression of pulmonary trunk/ artery. P Type I: entire aorta. Descending aorta Left hemothorax (sudden death) P Type II: ascending aorta and/or the arch of aorta Rarely into esophagus (profuse hematemesis) P Type III: descending aorta. Abdominal aorta Retroperitoneal hemorrhage (back pain with shock) Rarely intraperitoneal (shock and acute abdomen) è Occlusion of branches causes distal organ ischemia: Coronary ST elevation myocardial infarction Common carotid Any type of stroke Subclavian An acutely ischemic upper limb Coeliac/mesenteric Ischemic bowel Renal Frank hematuria Spinal Sudden onset painless paraplegia è Acute or progressive aortic regurgitation: P Diastolic murmur P Hemopericardium  Chest pain - Clinical assessment è Management è History: P Opiate analgesia: morphine P Is the most essential part of the assessment. P Type A: require open surgery P The most common symptom is pain P Type B: managed medically § Site (type A): anterior chest 70-80% and back pain P Control of blood pressure: intravenous labetalol (interscapular) occurs only in 50%. § Sudden in onset, tearing and sharp on nature. Tension Pneumothorax P In 5-15% of patients, no pain occurs at all and presenting with syncope, stroke, CHF or the elderly. - It’s a life-threatening condition caused by the continuous entrance and entrapment of air into the pleural space. è Physical examination - Compressing the lungs, heart, blood vessels. P Signs relating to hemopericardium: pulsus paradoxus, - Mechanism: one-way valve air entrapment. absent heart sounds, distended neck veins, shock P Signs relating to aortic root dilatation: wide pulse - Clinical picture: è Chest pain and shortness of breath pressure, diastolic murmur over the aortic area è Decreased breath sounds P Compression of the true aortic lumen: systolic è Hyperresonance on persecution murmur over any part of the aorta è Trachea deviates away from affected side P Pulse deficits: a difference of 20 mmHg or more in è Tachycardia, tachypnea blood pressure between arms. è Hypotension, hypoxemia P If the patient is hypotensive quickly determine whether this is 2ry to hypovolemia, pump failure or neurogenic as the treatment is very different. - Management: è Immediate needle decompression è Investigation: è Subsequent tube thoracostomy P ECG: not as helpful P CXR: wide mediastinum, hemopericardium, effusion. P CT scan: sensitivity ranging between 83 and 100%. - It’s clinically diagnosed and treated before doing CXR P TEE: ideal test because it can be performed in the resuscitation room, has a sensitivity of 90-98%