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Chest Pain

Chest Pain. William Beaumont Hospital Department of Emergency Medicine. The things that kill…. Acute MI PE Pneumothorax (ptx) Aortic Dissection Esophageal Rupture (Boerhaave’s). Let’s dive right in …. Chest Pain: what is it?.

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Chest Pain

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  1. Chest Pain William Beaumont Hospital Department of Emergency Medicine

  2. The things that kill… • Acute MI • PE • Pneumothorax (ptx) • Aortic Dissection • Esophageal Rupture (Boerhaave’s)

  3. Let’s dive right in…

  4. Chest Pain: what is it? 65 y/o male complains of substernal chest pressure and tightening that radiates to his left arm, shortness of breath, diaphoresis, and nausea that started while working in the yard. Pmhx: HTN, high cholesterol Soc: + tobacco FHx: father died at 62 of MI

  5. Chest Pain: what is it? 86 y/o female presents with generalized weakness, mental status changes, vomiting, epigastric pain, and syncope after her last episode of vomiting. There is no other history as the NH did not feel it was necessary to send her records.

  6. Chest Pain: what is it? 36 y/o obese, diabetic male presents with weakness, fatigue. shortness of breath whenever he gets off the couch, and “just not feeling right, doc.” Pmhx: diabetes since his teens, HTN, high cholesterol FHx: mom – HTN, dad- “had a bad heart”

  7. Acute Coronary Syndrome (ACS) • Includes USA, NSTEMI, STEMI • Leading cause of death among adults in the US (about 1 million, 2006) • 6 million people present to the ER per year with chest pain, 2 million of these receive the diagnosis of ACS • Cost of doing business: $100-120 billion

  8. Typical Male Older Age Tobacco HTN DM High Cholesterol FHx Cocaine Artificial/early menopause Atypical DM Elderly Female Nonwhite Dementia No history of MI No history of high cholesterol CHF CVA Risk factors for CAD

  9. Unstable Angina (USA) Defined • New onset angina occurring with minimal exertion or at rest, worsening of previous angina, increased frequency or duration of attack, and resistance to previous treatment • USA should be treated aggressively as it may be the precursor to AMI -> Admit to step down unit, IV NTG (if CP continues), IV Heparin, aspirin • ECG: normal/unchanged, nonspecific ST segment changes, or T wave inversions

  10. Acute Myocardial Infarction (AMI)Definition • Rise and fall of cardiac biomarkers with the following • Ischemic symptoms (critical vessel stenosis with increased myocardial work load or plaque rupture) • Development of q waves on ecg • ST segment elevation or depression (STEMI and NSTEMI) • Coronary artery intervention (lytics or cath lab) • Pathologic findings of acute MI

  11. NSTEMI Definition • Positive cardiac enzymes in the appropriate clinical scenario without ST elevation on the ecg • Ecg – normal, t wave inversions, ST segment depressions

  12. ECG Findings of ACS • Hyperacute T waves • ST segment elevation of 1 mm • ST segment depression – NSTEMI vs reciprocal changes • T wave inversions – initial presentation or evolving infarct • Q waves – may emerge in the initial hour, but usually develop at 8-12 hours • Normal ECG

  13. Injury Patterns on the ECG Anterior wall MI: ST segment elevation V1-V4 Vessel: LAD

  14. Injury Patterns on the ECG Anterior wall MI: ST segment elevation V1-V4

  15. Injury Patterns on the ECG Lateral Wall MI: I, aVL, V5, V6 Vessel: variable perfusion of LAD, RCA, LCx

  16. Injury Patterns on the ECG Anterolateral with reciprocal changes Vessels: LAD and 1st diagonal branch

  17. Injury Patterns on the ECG Inferior wall MI: II, III, aVF Vessel: 90% RCA, 10% LCx

  18. Injury Patterns on the ECG Posterior Wall MI: V1-V3 depression, tall upright T, tall wide R wave, R/S ratio greater than 1 Vessel: RCA, PDA, LCx

  19. Injury Patterns on the ECG Inferior Wall MI with Posterior Wall MI: V1-V3 depression, tall upright T, tall wide R wave, R/S ratio greater than 1 Vessel: RCA, PDA, LCx

  20. Injury PatternsWhat is this?

  21. Injury PatternsPericarditis: diffuse ST elevation except aVR

  22. Moving on… What do you want to order in addition to an ecg for a patient presenting with chest pain, suspected ACS?

  23. Initial Evaluation • IV, O2, monitor • Focused H&P • CBC • Chem 7 • CK-MB, troponin, myoglobin • CXR • PT/PTT • Possible d-dimer • ? Repeat ecg

  24. Treatment in the EC: STEMI/AMI • Activate the AMI page and cath lab • ASA 325mg po – proven to save lives • NTG SL and gtt- reduces preload>afterload, dilates coronary arteries • Heparin 60 U/kg bolus then 16 U/kg/hour • B Blocker – decrease catecholamine driven tachycardia and contractility, therefore decreasing myocardial oxygen demand

  25. Treatment in the EC: STEMI/AMI • Morphine – for persistent pain or anxiety to reduce O2 need, weak sympathetic blocker, preload reducer through venous dilation • Glycoprotein IIb/IIIA inhibitors – started in the EC or cath lab for those patients undergoing mechanical coronary intervention • Plavix – in consultation with the cardiologist as it prohibits CABG for 5 days

  26. Treatment in the EC: STEMI/AMIReperfusion Therapy • PCI – the 90 minute rule • Most people are eligible • Decreased risk of bleeding and stroke • Higher initial reperfusion rates • Defines coronary vasculature and allows for treatment vs. surgical referral • t-PA – when PCI cannot be achieved in 90 minutes or is not available at the institution • 0-12 hours after symptom onset

  27. NTG When to think twice?

  28. NTG: be cautious… • Bradycardia • Hypotension • Inferior or posterior wall MI with RV INFARCT • Decreased preload will cause sudden hypotension and increase infarct size • These patients need fluids to increase preload and help fill the malfunctioning/weakened ventricle

  29. Treatment in the EC: USA/NSTEMI • Basically the same, but without the cath lab or fibrinolytics • IV, O2, monitor • ASA, heparin, ntg, B blocker, morphine • Plavix and G IIb/IIIa inhibitors potentially after discussion with cardiology • Admit to a monitored unit

  30. Chest Pain: low risk, but risky enough • Patients who are low risk with risk factors (silly isn’t it?), chest pain free, and have a normal ecg and enzymes • Observation unit for serial cardiac enzymes and ecg • Stress test vs. CTA • Cardiology consult variable

  31. Questions about ACS?

  32. Chest Pain: what is it? 38 y/o female presents with sudden onset of chest pain and shortness of breath shortly after retrieving her bags at the baggage claim from a flight home from Hawaii. She states that it is worse when she takes a deep breath. She also complains of this aching pain in her R leg when walking.

  33. Chest Pain: What is it? 80 y/o bedridden patient sent from the NH with mental status changes and hemoptysis. She is pleasant during the conversation, but has no idea why she is here. She is actively coughing and appears to have increased work of breathing. Vitals: HR 110 BP 90/60 RR 28 sPO2 88% RA Lungs: bibasilar rales with R mid lung rhonchi PMHx: positive for almost everything (she is 80)

  34. Chest Pain: What is it? 29 y/o obese white female with history of fibromyalgia and chronic back pain presents with R neck and shoulder pain. She woke-up with it this morning, it is similar but worse than her usual aches. It hurts to move, turn, breathe, and live. She went to work today, but the aching was so bad that she had to come to the ER. Chart review shows that she was here 3 weeks ago for similar pain in her neck and lower back. Vitals: HR 126 BP 130/90 RR 28 sPO2 90% RA

  35. PE – 2006 stats • Approximately 1 in every 500-1000 EC patients has a PE • ECPs correctly diagnose about 50% • 10% of EC patients with PE die within 30 days even when PE is promptly diagnosed and treated

  36. RISK FACTORS Carcinoma Immobility Trauma or surgery in the last 4 weeks Smoking Estrogen/OCP Pregnancy/PP Thrombophilia Connective Tissue Dz Prior PE or DVT Signs and Symptoms Chest Pain Dyspnea Hemoptysis Splinting Syncope HR > 100 Pulse ox < 95% Unilateral arm or leg swelling PE

  37. PE - Diagnosis • Basic Labs – CBC and Chem 7 • ? Labs – ck-mb, troponin, PT/PTT • D dimer- low risk patients only with low pretest probability • CXR • exclude other diagnosis – CHF, pna, ptx • unilateral basilar atelectasis increases the probability of PE • Hamptom’s hump – wedge shaped infarction • Westermark’s sign – unilateral lung oligemia

  38. Hampton’s Hump Westermark’s Sign PE - CXR

  39. PE - Diagnosis • Ecg • Again to exclude other diagnosis • Most common finding is sinus tachycardia • T wave inversions v1-v4 • McGinn-White Pattern – s1q3t3 • New incomplete or complete RBBB • Chest CT – moderate to high risk patients or pre-test probability, positive d-dimer

  40. PE - ECG

  41. PE - ECG

  42. PE - Treatment • Heparin unfractionated 80 u/kg bolus then 18 u/kg/hour • LMWH 1 mg/kg SQ q12 hours • Coumadin – usually started on the floor • IVC filter – for pts who failed anticoagulation or have contraindications • Thrombolytics – consider in high risk pts such as systolic hypotension, persistent hypoxemia, elevated troponin or BNP (early shock or shock) • Surgery – large clot burden, refractory hypotension, floating emboli in the R heart

  43. PEAny Questions?

  44. Chest Pain: What is it? 18 y/o tall, thin healthy male c/o sudden onset L sided CP with shortness of breath. The pain started while he was inhaling on a marijuana cigarette. It hurts more to breathe. Vitals: HR 110 RR 28 BP 110/70 sPO2 96%

  45. Chest Pain: What is it? 60 y/o male with a history of severe COPD c/o increasing shortness of today that is not relieved with his home inhalers. Vitals: HR 110 RR 28 BP 110/70 sPO2 90% Heart: distant, tachycardic and regular Lungs: diffuse wheezing, decreased breath sounds on the right

  46. Pneumothorax • Primary Spontaneous – occurs in people without clinically apparent lung disease • 15/100,000 in men, 5/100,000 in women • Associated factors = tall, smoking, changes in ambient atmospheric pressure, genetics, MVP, Marfan’s syndrome • Disruption of the alveolar-pleural barrier is thought to occur when a bleb or bulla ruptures into the pleural space

  47. Pneumothorax • Secondary Spontaneous – occur with known underlying pulmonary disease • Three times more common in men • Associated with any underlying pulmonary disease including infection, ILD, neoplasms, COPD, asthma, etc… • Weakening of the alveolar-pleural barrier occurs secondary to the underlying lung disease either from inflammation or development of bullae

  48. Pneumothorax • Iatrogenic • Complication of intubation or aggressive BVM, central line placement, or any endoscopic procedure involving the trachea or esophagus • Consider in any stable patient with acute deterioration, hypoxia, or increased difficulty with ventilation

  49. Tension Pneumothorax • Positive intrapleural pressure causes compression of the mediastinum and the contralateral lung • Pressure exceeding 15 to 20 mm Hg impairs venous return to the heart • Leads to cardiovascular collapse if not treated immediately -> this is a clinical diagnosis not a radiographic one!

  50. Symptoms Ipsilateral sharp CP Dyspnea Pleuritic pain Cough Signs Sinus tachycardia Hyperresonance Decreased breath sounds Unilateral enlargement of the hemithorax Splinting Hypoxia PneumothoraxClinical Presentation

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