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CHEST PAIN

CHEST PAIN. Emergency Medicine Core Curriculum. Myocardial Infarction Angina Pericarditis Aortic Dissection Pulmonary Embolism Pneumonia Pneumothorax. GI Etiology Muscle Skeletal Etiology. Differential Diagnosis. Core Curriculum: Chest Pain. 2. Case 1.

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CHEST PAIN

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  1. CHEST PAIN Emergency Medicine Core Curriculum

  2. Myocardial Infarction Angina Pericarditis Aortic Dissection Pulmonary Embolism Pneumonia Pneumothorax GI Etiology Muscle Skeletal Etiology Differential Diagnosis Core Curriculum: Chest Pain 2

  3. Case 1 • 40 yo white male presents to the ED with a 30 min history of squeezing substernal chest pain radiating to left shoulder and jaw associated with nausea and diaphoresis. At presentation, chest pain intensity is 9/10. Core Curriculum: Chest Pain 14

  4. Myocardial InfarctionHistory/Presentation • Age: > 35 years • Sex: male > female • Duration: > 2 minutes, > several days • Location: retrosternal, epigastric • Radiation: left jaw, shoulder, arm • Character: pressure, squeezing, burning, crushing, tightness, heaviness • Associated symptoms: nausea, vomiting, diaphoresis, SOB, light-headed, weakness • Intensity: Scale 1-10 Core Curriculum: Chest Pain 3

  5. Vital Signs • Temp: WNL • HR: WNL, tachycardic, bradycardic • RR: WNL, tachypnea • BP: WNL, hypotensive, hypertensive Core Curriculum: Chest Pain 4

  6. Triage • Medications • Allergies • PMHx • PSHx • FHx • Cardiac Risk Factors • Contraindications to thrombolytic therapy Core Curriculum: Chest Pain 5

  7. Physical Exam • GEN: WDWN W male in mod distress • HEENT: WNL, JVD • COR: NSR, Sinus Tachycardia, Sinus bradycardia, SEM, S3, S4, • CHEST: CTA Bilaterally, Basilar rales, rales throughout bilateral lung fields • ABD: Non-tender • BACK: without spinal or CVA tenderness • EXT: WNL, PVD, Pedal Edema, symmetric pulses • RECTAL: Hemocult - Core Curriculum: Chest Pain 10

  8. Major (7) CAD Male Hypertension DM Hypercholestremia Family Hx Smoking Minor (6) Obesity Hyperuricemia Menopause Hypothyroidism Steroid use Type A personality Risk Factors: Ischemic HD Core Curriculum: Chest Pain 6

  9. EKG • ST elevation > 1 mm in two consecutive leads • ST depression > 1 mm in two contiguous anterior leads (post MI) • New LBBB Core Curriculum: Chest Pain 7

  10. AMI

  11. IWMI

  12. CXR • WNL • Cardiomegaly • Pulmonary Congestion • Pulmonary Edema Core Curriculum: Chest Pain 11

  13. CXR CHF

  14. Thrombolytic Therapy ASA Nitrates TPA (Door to Drug time < 30 minutes) Heparin Beta - blockers Primary Angioplasty Cardiology present for transportation to Cardiac Catheterization Suite within 30 min ED Course Core Curriculum: Chest Pain 12

  15. Thrombolytic Contraindications Absolute contraindications: • Internal bleeding, bleeding disorder, persistent HTN, Pregnancy, any trauma or surgery in last two weeks that could result in bleeding into closed space • CNS neoplasm, aneurysm, AVM, Hx of hemorrhagic CVA, AMS • CVA in last 6 months, intracranial or intraspinal surgery in last 2 months, Hx of head trauma in last 1 month • Suspect aortic dissection, Pericarditis • Previous allergy to streptokinase product (does not preclude TPA) Core Curriculum: Chest Pain 8

  16. Thrombolytic contraindications Relative contraindications • Active PUD, CPR > 10 min, anticoagulated, hemorrhagic optho conditions, Hx of uncontrolled HTN • Hx of CVA > 6 months ago • Trauma or surgery >2 weeks ago but < 2 months ago • Central line placement Core Curriculum: Chest Pain 9

  17. Thrombolytic therapy Coronary Care Unit Primary Angioplasty Cardiac Catheterization Suite Disposition Core Curriculum: Chest Pain 13

  18. Case 2 • 55yo white male with prior history of CAD confirmed on angiogram, presents to the ED with decreased exercise tolerance, increasing use of sublingual nitroglycerin for control of his typical anginal pattern (retrosternal chest pain). Core Curriculum: Chest Pain 23

  19. AnginaHistory/Presentation • Age: > 35 years • Sex: male > female • Duration: 5 - 20 minutes • Location: retrosternal, epigastric • Radiation: neck, shoulder, arm • Character: pressure, squeezing, burning crushing, tightness, heaviness • Precipitated by exertion • Relieved with rest and/or nitrates Core Curriculum: Chest Pain 15

  20. Vital Signs • Temp: WNL • HR: WNL, tachycardic, bradycardic • RR: WNL, tachypnea • BP: WNL, hypertensive, hypotensive Core Curriculum: Chest Pain 16

  21. Triage • Medications • Allergies • PMHx • PSHx • FHx • Cardiac risk factors • Contraindications to thrombolytic therapy Core Curriculum: Chest Pain 17

  22. Physical Exam • GEN: WDWN W male in min distress • HEENT: WNL, JVD • COR: NSR, Sinus Tachycardia, Sinus bradycardia, SEM, S3, S4, • CHEST: CTA Bilaterally, Basilar rales, rales throughout bilateral lung fields • ABD: Non-tender • BACK: without spinal or CVA tenderness • EXT: WNL, PVD, Pedal Edema, symmetric pulses • RECTAL: hemocult - Core Curriculum: Chest Pain 19

  23. EKG • ST changes • Subendocardial ischemia • Prinzmetal’s Angina Core Curriculum: Chest Pain 18

  24. EKG - Angina

  25. CXR • WNL • Cardiomegaly • Pulmonary congestion • Pulmonary edema Core Curriculum: Chest Pain 20

  26. Stable Angina Pain relieved with NTG and rest No change in usual anginal pattern No EKG changes No evidence of CHF Unstable Angina New onset (< 2 months) Angina at rest Angina brought on walking < 2 blocks Pain unrelieved with sublingual NTG NTG drip required Increased frequency, severity/character of pain, increased NTG requirements ED Course Core Curriculum: Chest Pain 21

  27. Stable Angina Routine outpatient cardiology/medicine follow-up Outpatient echo, stress, catheterization to be determined by PMD Unstable Angina Coronary care unit Monitored bed Disposition Core Curriculum: Chest Pain 22

  28. Case 3 • 23 yo white male with a recently resolved URI presents with a 6 hour history of constant, stabbing substernal chest pain made worse with inspiration or movement and improved when the patient sits up and leans forward. Core Curriculum: Chest Pain 34

  29. PericarditisHistory/presentation • Age: all • Sex: no difference • Duration: sudden or gradual onset - constant • Location: retrosternal • Radiation: back, neck, left shoulder, arm • Character: sharp, stabbing • Aggravated by inspiration, movement • Relieved by leaning forward • Associated symptoms: fever, dyspnea, dysphagia Core Curriculum: Chest Pain 24

  30. Vital Signs • Temp: WNL, low-grade temp • HR: WNL, tachycardia • RR: WNL, tachypnea • BP: WNL, hypotensive Core Curriculum: Chest Pain 25

  31. Triage • Medications • Allergies • PMHx • PSHx • FHx • Cardiac risk factors • Contraindications to thrombolytic therapy Core Curriculum: Chest Pain 26

  32. Physical Exam • GEN: WDWN W male in min distress • HEENT: WNL, JVD • COR: WNL, pericardial friction rub • CHEST: CTA, basilar rales • ABD: soft, NT, Nml. BS • BACK: without CVA tenderness • EXT: no edema, symmetric pulses • RECTAL: hemocult - Core Curriculum: Chest Pain 29

  33. EKG • Evolutionary: 4 stages • Stage 1: hours to days • Diffuse ST elevations in all leads except AVR & V1 • Reciprocal changes in AVR and V1 • No T wave abnormality • PR depression • No Dysrhythmias • Stage 2: transiently normal EKG • Stage 3: deep Symmetrical Inversion of T waves • Stage 4: normal EKG or permanent T wave inversions Core Curriculum: Chest Pain 27

  34. Slide - EKG Pericarditis

  35. CXR • WNL • Increase in cardiothoracic ratio without pulmonary venous hypertension • On lateral, epicardial fat pad sign in 15 % • Echo/CT definitive Core Curriculum: Chest Pain 28

  36. Tamponade

  37. Differential Diagnosis • Acute Pericarditis: • Idiopathic • Viral vs. bacterial vs.. fungal infection • Malignancy • Drug induced • Connective tissue disease • Radiation-induced • Postmyocardial infraction (Dressler syndrome) • Uremia • Myxedema Core Curriculum: Chest Pain 30

  38. ED Course • Echocardiography: procedure of choice • Additional ancillary labs: • Streptococcal serology • Bld cultures • Acute and convalescent viral titers • ANA • TFT • ESR Core Curriculum: Chest Pain 31

  39. Treatment • Etiology directed. • Viral (majority): responds to 1-3 weeks of outpatient NSAIDS Core Curriculum: Chest Pain 32

  40. Outpatient: Viral etiology Hemodynamically stable Inpatient: Hemodynamically unstable All other etiologies Disposition Core Curriculum: Chest Pain 33

  41. Case 4 • 55 yo hypertensive white male presents with a 20 min history of severe shearing intrascapular back pain associated with left arm numbness and coolness.

  42. Aortic DissectionHistory/Presentation • Age: > 50 yo • Sex: predominantly male • Duration: severe at onset, constant • Location: retrosternal, intrascapular, above and below the diaphragm • Radiation: dependent on path of dissection • Character: cutting, searing, ripping, tearing Core Curriculum: Chest Pain 35

  43. Vital Signs • Temp: Afebrile • HR: variable, non-diagnostic • RR: WNL, slight tachypnea • BP: variable, non-diagnostic Core Curriculum: Chest Pain 36

  44. Triage • Medications • Allergies • PMHx • PSHx • FHx • Cardiac risk factors • Contraindications to thrombolytic therapy Core Curriculum: Chest Pain 37

  45. Physical Exam • GEN: WDWN elderly W male in severe distress • HEENT: WNL, facial droop, asymmetric carotid pulses, JVD • COR: RRR w/o murmurs, S3, S4, JVD, diastolic murmur • CHEST: CTA Bilaterally • ABD: soft, NT, Nml. BS, pulsatile mass, bruit • BACK: w/o CVA tenderness B • RECTAL: NST, Hemocult -/+ • EXT: symmetric pulses, asymmetric or absent pulses Core Curriculum: Chest Pain 40

  46. EKG • Non-specific changes • AMI Core Curriculum: Chest Pain 38

  47. CXR • Abnormal in 90 % of cases • Dilation of aortic shadow • Intimal calcification > 6 mm within the margin of the aortic shadow Core Curriculum: Chest Pain 39

  48. CXR Aortic Dissection

  49. Aortic Dissection

  50. DeBakey Aortic Dissection Classification

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