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CHEST PAIN

CHEST PAIN. Trifun Dimitrijevski, MD, FACEP Assistant Professor of Emergency Medicine Director Medical Simulation, Kado CSC Assistant Clerkship Director Wayne State University School of Medicine Detroit Receiving Hospital, DMC. DISCLOSURES. -> NONE!. CHEST PAIN.

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CHEST PAIN

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  1. CHEST PAIN Trifun Dimitrijevski, MD, FACEP Assistant Professor of Emergency Medicine Director Medical Simulation, Kado CSC Assistant Clerkship Director Wayne State University School of Medicine Detroit Receiving Hospital, DMC

  2. DISCLOSURES • -> NONE!

  3. CHEST PAIN • Accounts for approximately eight million annual visits to emergency departments (ED) in the United States. • Second most common complaint presenting to the ED.

  4. CHEST PAIN • Each year an estimated cost of over 10 billion dollars is spent evaluation chest pain. • Missed myocardial infarction represents approximately 10% of malpractice claims.

  5. CHEST PAIN • Clinicians in the ED focus on the immediate recognition and exclusion of life-threatening causes of chest pain. • Patients with life threatening etiologies for chest pain may appear deceptively well, manifesting neither vital sign nor physical examination abnormalities initially.

  6. CHEST PAIN • There are six life-threatening causes of chest pain: • Acute Coronary Syndrome (ACS). • Tension Pneumothorax. • Cardiac Tamponade. • Aortic Dissection. • Pulmonary Embolism. • Esophageal Rupture (Boerhaave’s).

  7. CHEST PAIN: Acute Coronary Syndrome • Results from significantly decreased or obstruction of blood flow through coronary arteries. • Mostly commonly results from atherosclerosis.

  8. CHEST PAIN: Acute Coronary Syndrome • As a result myocardial tissue distal to compromised flow is hypoperfused resulting in hypoxic/anoxic myocardium.

  9. CHEST PAIN: Acute Coronary Syndrome • Hypoxic myocardium becomes pro-arrhythmogenic with high likelihood of resulting in V-tach or V-fib.

  10. CHEST PAIN: Acute Coronary Syndrome • Symptoms: • Chest pain that occurs with exertion, relieved with rest. • Pain located retrosternal, described as pressure/heaviness. • May have radiating features to left shoulder, jaw, neck and arm.

  11. CHEST PAIN: Acute Coronary Syndrome • Associated symptoms may be present: • Shortness of breath • Diaphoresis • Nausea and vomiting • Palpitations • Lightheadedness, dizziness

  12. CHEST PAIN: Acute Coronary Syndrome • Assess Risk Factors: • Diabetes • Hypertension • Hypercholesterolemia • Significant family history • Smoking/cocaine use. • Pre-existing CAD.

  13. CHEST PAIN: Acute Coronary Syndrome • Management: • IV, O2, Pulse Ox, Monitor. • M – morphine • O – oxygen • N – nitrates • A – aspirin

  14. CHEST PAIN: Acute Coronary Syndrome • Management: • 12-Lead ECG • Chest X-ray • Electrolytes • CBC • Troponin • PT/PTT

  15. CHEST PAIN: Acute Coronary Syndrome • Disposition: • STEMI – Stabilize and Cath Lab immediately! • NSTEMI – Stabilize as needed, ASA, heparin, plavix, admission to telemetry bed/CCU as per case basis. • Chest Pain – If no STEMI/NSTEMI, stabilize, assess risk using TIMI score to determine ED rule-out and home with follow-up, or observation versus inpatient admit.

  16. CHEST PAIN: Acute Coronary Syndrome

  17. CHEST PAIN: Tension Pneumothorax • Results from a “one-way-valve” air leak either from lung or through the chest wall. • Penetrating injury • Ruptured bleb (COPD patients) • Spontaneous pneumothorax • Air is forced into the thoracic cavity without means of escape, collapsing the affected lung.

  18. CHEST PAIN: Tension Pneumothorax • Mediastinum is displaced to the opposite side, decreasing venous return, compressing other lung, cardiac output falls.

  19. CHEST PAIN Trauma Tension Pneumothorax Pneumothorax • Most common cause is mechanical ventilation with positive pressure ventilation in patient with a visceral pleural injury. • Clinical diagnosis, treatment never delayed for radiographic confirmation!

  20. CHEST PAIN: Tension Pneumothorax • Symptoms: • Chest pain • Air hunger • Respiratory distress • Tracheal deviation • Absent breath sounds • Distended neck veins

  21. CHEST PAIN

  22. CHEST PAIN: Tension Pneumothorax • Management: • IMMEDIATE DECOMPRESSION! • Inserting large-bore needle into second inter-costal space, midclavicular line on affected side. • Followed by chest tube insertion fifth intercostal space between anterior and midaxillary line.

  23. CHEST PAIN: Tension Pneumothorax • Disposition: • Once chest tube placed admission to surgery or MICU for chest tube management, resolution of pneumothorax • ?OR if pneumothorax persisting, worsening, patient unstable.

  24. CHEST PAIN: Cardiac Tamponade • Most commonly from penetrating injuries. • Pericardial sac is a fixed fibrous structure surrounding the heart. • Only a small amount of fluid (blood) is required to restrict cardiac activity and cause hemodynamic collapse.

  25. CHEST PAIN: Cardiac Tamponade • Symptoms: • Dyspnea • Tachycardia • Tachypnea • Chest Pain • Weak/Dizzy

  26. CHEST PAIN: Pericardial Tamponade • Diagnosis may be difficult. • Classic triad (Beck’s) of JVD, muffled heart tones and hypotension –> may not always be present or appreciated. • Other exam findings of pulsus paradoxus and Kussmaul’s sign may be present.

  27. CHEST PAIN: Pericardial Tamponade • Pulsus paradoxus – a normal physiologic decrease in systolic blood pressure that occurs with spontaneous inspiration. When decrease in systolic blood pressure exceeds 10 mmHg it is a sign of tamponade.

  28. CHEST PAIN: Pericardial Tamponade • Kussmaul’s sign – a rise in venous pressure with inspiration (when breathing spontaneously), is a true paradoxical venous pressure abnormality seen with tamponade. • PEA during trauma in the absence of hypovolemia and tension pneumothorax, is also suggestive of tamponade.

  29. CHEST PAIN:Pericardial Tamponade • Cardiac silhouette will often appear enlarged.

  30. CHEST PAIN: Pericardial Tamponade • Transthoracic ultrasound (echocardiogram) possibly beneficial, it is noninvasive and rapid. However has significant false-negative rate of 5%.

  31. CHEST PAIN: Pericardial Tamponade • Management: • Prompt evacuation of pericardial blood indicated for patients unresponsive to resuscitative efforts for hemorrhagic shock and who have potential for tamponade. • Pericardiocentesis should not be delayed for any diagnostic adjunct in this setting. • ->Subxyphoid method.

  32. CHEST PAIN: Pericardial Tamponade • Disposition: • To OR for pericardial window. • All patients with positive pericardiocentesis resulting from trauma will require open thoracotomy or median sternotomy for inspection of the heart.

  33. CHEST PAIN: Aortic Dissection • Occurs when a tear in the inner wall of the aorta causes blood to flow between the layers of the wall of the aorta, forcing the layers apart. • Dissection typically extends anterograde, but can extend retrograde from the site of the intimal tear.

  34. CHEST PAIN: Aortic Dissection • It is a medical emergency and can quickly lead to death, even with optimal treatment. • Dissections resulting in rupture have an 80% mortality rate, and 50% of patients die before they even reach the hospital.

  35. CHEST PAIN: Aortic Dissection • Symptoms: • Severe pain sudden in onset and sharp. • Tearing, stabbing, ripping. • Radiation of pain up and down chest/back. • Numbness/tingling in arms/legs. • Abdominal pain. • Weakness.

  36. CHEST PAIN: Aortic Dissection • Management: • IV, O2, Pulse Ox, Monitor. • Blood Pressure Control!!! (Paramount) • Rapidly acting B-blocker, titratable (Esmolol) • Vasodilating agent (Sodium Nitroprusside*) • Alternatives (Labetalol, Diltiazem) • Goal for BP control; (A-Line) • MAP 60 – 70 mmHg, Systolic 100 – 110 mmHg. • Analgesics.

  37. CHEST PAIN: Aortic Dissection • Management: • Chest X-ray. • 12-Lead ECG. • Electrolytes. • CBC. • Troponin • PT/PTT. • Type and screen.

  38. CHEST PAIN: Aortic Dissection • Classification (DeBakey): • Type I – Originates in ascending aorta, propagates at least to the aortic arch and often beyond it distally. It is most often seen in patients less than 65 years of age and is the most lethal form of the disease. • Type II – Originates in and is confined to the ascending aorta. • Type III – Originates in descending aorta, rarely extends proximally but will extend distally. It most often occurs in elderly patients with atherosclerosis and hypertension.

  39. CHEST PAIN: Aortic Dissection • Classification (Stanford): • A – Involves the ascending aorta and/or aortic arch, and possibly the descending aorta. The tear can originate in the ascending aorta, the aortic arch, or, more rarely, in the descending aorta. It includes DeBakey type I, II and retrograde type III (dissection originating in the descending aorta or aortic arch but extending into the ascending aorta). • B – Involves the descending aorta or the arch (distal to right brachiocephalic artery origin), without involvement of the ascending aorta. It includes DeBakey type III without retrograde extension into the ascending aorta.

  40. CHEST PAIN: Aortic Dissection

  41. CHEST PAIN: Aortic Dissection • Chest X-ray findings: • Widening of the mediastinum. • Obliteration of the aortic knob. • Depression of the left mainstem bronchus. • Loss of the paratracheal stripe. • Tracheal deviation. • Pleural Effusion. • 12 to 20% of individuals presenting with an aortic dissection have a "normal" chest x-ray.

  42. CHEST PAIN: Aortic Dissection • Advanced Imaging: • CT - fast non-invasive test that will give an accurate three-dimensional view of the aorta. • Sensitivity and specificity of 96 to 100%. • Disadvantages include the need for iodinated contrast material and the inability to diagnose the site of the intimal tear.

  43. CHEST PAIN: Aortic Dissection • Advanced Imaging: • MRI - Currently the gold standard test for the detection and assessment of aortic dissection. • Sensitivity/specificity of 98% • Will produce a three-dimensional reconstruction of the aorta, allowing to determine the location of the intimal tear, the involvement of branch vessels, and locate any secondary tears. • Disadvantages - limited availability and the scan is relatively time consuming.

  44. CHEST PAIN: Aortic Dissection • Disposition: • Aggressive BP control. • Involve cardiothoracic surgeon early. • Admit to ICU. • Surgery not indicated for all dissections. • Only for acute proximal aortic dissection and an acute distal aortic dissection with one or more complications*. *Complications include compromise of a vital organ, rupture or impending rupture of the aorta, retrograde dissection into the ascending aorta, and a history of Marfan syndrome or Ehlers-Danlos Syndrome.

  45. CHEST PAIN: Pulmonary Embolism • Most commonly results from deep vein thrombosis that breaks off and migrates to the lung, obstructing one or more pulmonary arteries or its branches. • Results in elevated pressure on the right ventricle, causing ventilation and perfusion abnormalities and thus symptoms. • Risk Factors: Cancer, immobility, pregnancy

  46. CHEST PAIN: Pulmonary Embolism • Symptoms: • Difficulty breathing • Chest pain on inspiration • Palpitations • Collapse • Death

  47. CHEST PAIN: Pulmonary Embolism • Management: • IV, O2, Pulse Ox, Monitor • Fluids to support circulation if needed • Chest X-ray • 12-Lead ECG • Electrolytes • CBC • PT/PTT • Troponin

  48. CHEST PAIN: Pulmonary Embolism • Management: • D-Dimer vs. CT-Scan? • Low risk probability -> D-Dimer • Moderate – High Risk -> CT-Scan • Wells Criteria

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