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APPROACH TO CHEST PAIN

APPROACH TO CHEST PAIN. DR. PRAKASH MOHANASUNDARAM EMERGENCY PHYSICIAN Department of Accident, Emergency & Critical Care Medicine. Vinayaka Mission Kirupananda Variyar Medical college Hospital, Salem, Tamilnadu, India . www.emergencymedicineindia.com. BACKGROUND.

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APPROACH TO CHEST PAIN

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  1. APPROACH TO CHEST PAIN DR. PRAKASH MOHANASUNDARAM EMERGENCY PHYSICIAN Department of Accident, Emergency & Critical Care Medicine. Vinayaka Mission Kirupananda Variyar Medical college Hospital, Salem, Tamilnadu, India. www.emergencymedicineindia.com

  2. BACKGROUND • Approx 5% of all ED visits • 15% - AMI • 25-30% - Unstable angina • 14 -34% - Other conditions • Atypical presentations – common

  3. ACUTE CHEST PAIN • Recent onset, typically less than 24 h • Location described on the anterior thorax • A noxious uncomfortable sensation distressing to the patient.

  4. CATEGORISATION • Visceral pain • Pleuritic pain • Chest wall pain

  5. Typical exertional angina Atypical angina Unstable angina Acute myocardial infarction Aortic dissection Pericarditis Oesophageal reflux or spasm Oesophageal rupture Mitral valve prolapse VISCERAL PAIN

  6. Pulmonary embolism Pneumonia Spontaneous pneumothorax Pericarditis Pleurisy PLEURITIC PAIN

  7. Costosternal syndrome Costochondritis Precordial catch syndrome Slipping rib syndrome Xiphodynia Radicular syndromes Intercostal nerve syndromes Fibromyalgia CHEST WALL PAIN

  8. 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jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea variable variable variable variable variable variable variable variable variable variable variable variable variable variable variable variable variable variable variable variable variable variable variable variable variable variable variable variable variable variable angina angina angina angina angina angina angina angina angina angina angina angina angina angina angina angina angina angina angina angina angina angina angina angina angina Angina angina angina angina angina visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal 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<15 min <15 min <15 min <15 min <15 min <15 min <15 min <15 min <15 min <15 min <15 min <15 min <15 min <15 min <15 min <15 min <15 min <15 min <15 min <15 min <15 min <15 min <15 min <15 min <15 min <15 min Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea gradual gradual gradual gradual gradual gradual gradual gradual gradual gradual gradual gradual gradual gradual gradual gradual gradual gradual gradual gradual gradual gradual gradual gradual gradual gradual gradual gradual gradual gradual

  9. Etiology Quality Location Radiation Duration Asso. Symptoms Onset Aortic dissection severe retrosternal Inter scapular tearing constant Nausea diaphoresis, dyspnoea Sudden PE pleuritic lateral constant dyspnoea sudden Pneumothorax pleuritic lateral Neck, back constant dyspnoea sudden

  10. SCENARIO - 1 • 40 year old gentleman comes to ER with h/o chest pain, breathlessness, sweating since 2 hrs • Chest pain retrosternal, crushing type, non radiating lasting for 2 hrs • H/O hypertension for the past 3 years, • Known smoker and a genetic h/o heart disease.

  11. BP-110/60 HR-104 RR-34 SPO2-95% CVS – Tachycardia RS - Tachypnoea PA - Soft CNS- NFND VITALS

  12. What r the initial assesment?DD?

  13. Immediate Assessment (<10 min) Cardiac marker levels Electrolytes Coagulation studies Vital signs / O2 sat IV Access ABC Brief history Fibrinolytic checklist Physical examination 12 Lead ECG CXR (EARLY)

  14. Describe your immediate general treatment?

  15. Immediate General Treatment ONAM OXYGEN NITRATES MORPHINE ASPIRIN

  16. Assess Initial 12-Lead ECG • Classify patients with acute ischemic chest paininto 1 of 3 ECG classification groups: • STEMI • NSTEMI / UA • Nondiagnostic or Normal

  17. ….ECG STEMI ST elevation / presumed new LBBB 0.1mv or 1mm in 2 or more contiguous precordial leads or 2 or more adjacent limb leads. UA/NSTEMI ST dep ≥ 0.5 mm (0.05mv) or dynamic T inversions with pain or discomfort Non-persistent or transient ST elevation >0.5mm for less than 20 mins Nondiagnostic ST deviation <0.5 mm or T inversions <0.2 mm

  18. “ J “ POINT J point plus 0.04 second ST-segment deviation= 4.5 mm PP baseline The point at which the ST segment originates from the QRS complex is called the J point

  19. ST-T Changes

  20. How to identify LBBB • Deep S wave in V1 and a tall late R wave in lead I and/or V6,wide QRS complexes • WILLIAM • Serial Cardiac markers for confirmation

  21. ECG diagnosis of LBBB

  22. AMI Localization I lateral aVR V1 septal V4 anterior II inferior aVL lateral V2 septal V5 lateral V6 lateral III inferior aVF inferior V3 anterior

  23. INFERIOR WALL MI, RVMI

  24. Acute Inferior MI

  25. True Posterior MI

  26. CARDIAC MARKERS Limited role in case of diagnostic ST elevation in ECG Role in pts with nondiagnostic ECG changes Early diagnosis Missed MI Early risk stratification Requires Serial Measurements rather than single (every 2-3 hours)

  27. …CARDIAC MARKERS CK : Levels twice upper limit of normal = abnormal Rises within 4-8hrs & falls within 3-4 days False + results CK-MB isoenzyme: More specific False + AST : rise 18-36hrs post MI LDH : rise 24-36hrs post MI

  28. …CARDIAC MARKERS TROPONINS TnI more sensitive and specific in serial testing & not at presentation. Starts to rise by 6 hrs & persists upto 7-10 days. (diagnose late MI) Also elevated in myocarditis ,CM & pericarditis

  29. DIAGNOSTIC CRITERIA(ANY TWO OUT OF THREE) • Typical history • ECG changes • Cardiac enzyme elevation CK CKMB TROPONIN

  30. Goals of treatment • Door to needle time < 30 mins (thrombolysis) • Door to balloon time < 90 mins (reperfusion)

  31. SCENARIO - 2 • A 40 year male, brought to ER with h/o sudden onset chest pain & breathlessness since 2 hrs. • Pleuritic pain, constant over the anterior thorax • Has travelled from USA to INDIA 3 hrs back • Chronic smoker

  32. BP-100/60; HR-146; RR-42; SPO2-88% TROPONIN I – not raised CVS- tachycardia RS – tachypnoea PA – soft CNS - NFND VITALS

  33. PULMONARY EMBOLISM Pulmonary embolism (PE) is a blockage of the pulmonary artery or one of its branches, usually occuring when a venous thrombus becomes dislodged from its site of formation and embolizes to the arterial blood supply of one of the lungs.

  34. FACTS • > 50 % pts with DVT are associated with PE • > 50 % cases do not have any signs or symptoms • Common presentation can be unexplained tachycardia, tachypnoea, hypoxemia or mere anxiety • Diagnosis and suspicion is purely clinical

  35. Clinical Features Symptoms in Patients with Angio Proven PTE Symptom Percent Dyspnea 84 Chest Pain, pleuritic 74 Anxiety 59 Cough 53 Hemoptysis 30 Sweating 27 Chest Pain, nonpleuritic 14 Syncope 13

  36. Clinical Features Signs with Angiographically Proven PE Sign Percent Tachypnea > 20/min 92 Rales 58 Accentuated S2 53 Tachycardia >100/min 44 Fever > 37.8 43 Diaphoresis 36 S3 or S4 gallop 34 Thrombophebitis 32 Lower extremity edema 24

  37. ECG Most Common Findings: Tachycardia or nonspecific ST/T-wave changes Acute cor pulmonale or right strain patterns Tall peaked T-waves in lead II (P pulmonale) Right axis deviation RBBB S1-Q3-T3 (occurs in only 20% of PE patients) Atrial fibrillation / Atrial flutter

  38. Chest X ray Westermark’s sign focal oligemia / cut off sign Hampton’s hump peripheral wedge shaped density above the diaphragm Palla’s sign enlarged right descending pulmonary artery ALMOST ALWAYS NORMAL CHEST X-RAY

  39. WESTERMARK’S SIGN HAMPTON’S HUMP PALLA’S SIGN ALMOST ALWAYS NORMAL CHEST X-RAY

  40. Pulmonary Angiography (GOLD STANDARD) Arrow indicates abrupt termination of a pulmonary artery. Www.brighamrad.Harvard.edu/cases/bwh/images.

  41. RISK STRATIFICATION

  42. Heparin / LMWH / Warfarin • Heparin 80 U/kg iv bolus foll by 18 U/kg/hr • Enoxaparin 1 mg/kg twice daily / 1.5 mg/kg daily • Tinzaparin 175 mg/kg OD • Fondaparinux <50 kg receive 5 mg, 50–100 kg patients receive 7.5 mg >100 kg receive 10 mg. • Warfarin – 2.5 to 10 mg Target INR – 2.0 TO 3.0

  43. THROMBOLYSIS • Recombinant tPA 100 mg iv infusion over 2 hours • Streptokinase 250,000 U iv over 30 mins foll by 100,000 U/hr for 24 hrs • Urokinase 4,4OO U/kg iv over 10 mins foll by 4,000 U/kg/hr for 12 hrs • Alteplase 15 mg iv bolus foll by 2 hr infusion of 85 mg ( discontinue heparin during infusion)

  44. EMBOLECTOMY Indicated in pts with risk of thrombolysis • Surgical embolectomy • Catheter embolectomy

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