1 / 44

APPROACH TO Pt WITH CHEST PAIN

APPROACH TO Pt WITH CHEST PAIN. CAUSES OF CHEST PAIN. DIFFERENCE B/W ISCHEMIC AND NON ISCHEMIC PAIN. APPROACH TO THE Pt WITH CHESTPAIN. Initial Stabilization Obtaining the Chest Pain History The Physical Exam in Chest Pain Diagnostic Maneuvers Monitoring the Patient During Work-up

karis
Download Presentation

APPROACH TO Pt WITH CHEST PAIN

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. APPROACH TO Pt WITH CHEST PAIN

  2. CAUSES OF CHEST PAIN

  3. DIFFERENCE B/W ISCHEMIC AND NON ISCHEMIC PAIN

  4. APPROACH TO THE Pt WITH CHESTPAIN • Initial Stabilization • Obtaining the Chest Pain History • The Physical Exam in Chest Pain • Diagnostic Maneuvers • Monitoring the Patient During Work-up • Laboratory Evaluation of Chest Pain • Disposition of the Chest Pain Patient • Thrombolytics

  5. HISTORY • Previous episodes • Onset • Quality • Severity • Location • Duration • Pattern of radiation • Aggravating or alleviating factors

  6. PHYSICAL EXAMINATION • General appearance • Vital signs • Neck • Lung • CV • Abdomen • Extremities • Neuro-cognitive

  7. TM MANEUVERS • Sublingual nitroglycerine • Repeat after 2 min • GI coctail-antacid with lidocain • morphine

  8. Diagnostic Studies • Blood Tests : • Blood CBC • Cardiac Enzymes [CK-MB, Troponin I] • LDH • CPK • ECG • Chest X-Ray • Cardiac Catheterization

  9. LAB EVALUATION OF CHEST PAIN1-ECG

  10. LAB EVALUATION 2.(Radiography (CXR) –pnemothorax or pnemomediastinum. 3.Pulse oximetry or ABG • Cardiac enzymes: only if needed • CPK/MB: 6-48 hr (early and repeat x3) • Troponins: 12 hr-1 wk (false positives do occur) 4.Myoglobin: less used but long half-life 5 Blood CP,clotting profile,electrolytes,RFTs 6 Other: CT +/- Angio, V/Q scan, D-dimer, Echocardiogram. • Abd UGS

  11. Characteristics Myoglobin Troponin CK-MB LDH 24000 I 36000 T MW 18000 86000 135000 Increase 2-3h 4-5h 3-8h 8-12h Peak 6-9h 10-24h 10-24h 2-4h Return to normal 5-8d (12d) 18-24h 2-3d 5-15d

  12. MONITIRING Pt DURING WORKUP • Attach pt to cardiac monitor, pulse oximeter • Vitals monitoring • Note any change in symptoms e.g sweating, respiratory rate or effort, skin colour.

  13. “The Big Five”Five life-threatening causes of Chest Pain • Acute coronary syndrome • Aortic dissection • Pulmonary Embolism • Tension Pneumothorax • Esophageal Rupture

  14. Angina • described as a pressure-like, squeezing, crushing, or tight pain • often radiates to the jaw, shoulders or arms • can be accompanied by nausea, sweating, shortness of breath, dizziness, weakness, or fatigue

  15. Acute myocardial ischemia • History: • Sudden sub-sternal crushing chest pain with radiation to the left arm/jaw • Worse with exercise (history of worsening) • Associated with shortness of breath, profuse sweating, and nausea/vomiting • Cardiac risk factors: high blood pressure, diabetes, high cholesterol, family history, tobacco use, and cocaine use • Past history of CAD/MI

  16. Acute myocardial ischemia • ECG Changes

  17. Myocardial Ischemia Troponin I, CK-MB, myoglobin, and total CK are markers of cell injury Cell Death

  18. Management ROMI = Rule Out MI Serial enzymes Serial ECG’s Telemetry monitoring Definitive testing? Research we do here may change this

  19. Imaging – Stress Test • Identifies changes in perfusion using a radioactive tracer at rest and during exercise www.tmc.edu www.kelsey-seybold.com Tells you only about fixed defects. Does not provide information about location of blockage, degree of stenosis, or shape of thrombus.

  20. Imaging – CT Coronary Angiogram • Timed administration of contrast dye to look at coronaries Tells you about the degree of stenosis; fast, cheap, and low risk, but another intervention is required if a blockage is seen

  21. Imaging – Cardiac Catheterization • Higher risk • Patient must be admitted into the hospital • Can view degree of blockage and intervene www.guidant.com www.lvhhn.org

  22. Acute myocardial ischemia • Exam: • New murmur, heart sounds, elevated neck veins • Very limited utility • Testing • ECG Changes • Elevated cardiac markers • Positive stress test, cardiac cath, coronary CT angiogram

  23. Myocardial Ischemia: Treatment • Prevent more clot from forming • Asprin (ASA), heparin, clopidogrel (Plavix), glycoprotein IIb/IIIa inhibitors, others • Increase oxygen delivery and decrease demand • Control blood pressure • Give supplemental oxygen • Pain control • Morphine • Give meds to dissolve the existing clot • Streptokinase, tissue plasminogen activator • Cardiac catheterization with percutaneous coronary intervention (angioplasty and stenting) • Coronary artery bypass graft (CABG) – open-heart bypass surgery

  24. Management of MI : • prevent more clot formation • asprin (ASA), heparin, clopidogrel, glycoprotein IIb/IIIa inhibitors, etc • increase oxygen delivery and decrease demand • control blood pressure • give supplemental oxygen • analgesics • morphine • give medications to dissolve the existing clot • streptokinase, tissue plasminogen activator • cardiac catheterization with percutaneous coronary intervention angioplasty and stenting • coronary artery bypass graft (CABG) – open-heart bypass surgery

  25. Management of MI : • prevent more clot formation • asprin (ASA), heparin, clopidogrel, glycoprotein IIb/IIIa inhibitors, etc • increase oxygen delivery and decrease demand • control blood pressure • give supplemental oxygen • analgesics • morphine • give medications to dissolve the existing clot • streptokinase, tissue plasminogen activator • cardiac catheterization with percutaneous coronary intervention angioplasty and stenting • coronary artery bypass graft (CABG) – open-heart bypass surgery

  26. Myocardial ischemia: Treatment

  27. Pulmonary Embolism

  28. Pulmonary Embolism • History: Pleuritic chest pain (pain is worse when taking a deep breath), sudden onset, difficulty breathing, history of stasis, past clots, or leg swelling/pain • Exam: wheezing in the lung, rapid heart rate, low blood pressure, usually normal oxygen saturation, leg swelling (unilateral often) • Test: D-dimer, V/Q scan, chest CT • Treatment: anti-coagulation (“blood thinners”); consider thrombolytics (“clot-busters”) or surgical removable if severe

  29. Tension Pneumothorax • Occurs when air can get into chest but can’t get out • Collapses lung and puts pressure on vessels/heart leading rapidly to dangerously low blood pressure • Clinical Diagnosis: sudden onset of shortness of breath, low blood pressure, and rapid heart rate; absent breath sounds over affected hemithorax; seen in young and old • Treatment: immediate needle thoracostomy to relieve pressure followed by chest tube

  30. Tension Pneumothorax Normal Tension Pneumothorax

  31. Pericarditis with Temponade • Pericarditis is an infection of the tissues surrounding the heart • Inflammation causes build-up of fluid in the closed space around the heart • History: hours to days of sharp chest pain, often positional (better when leaning forward), shortness of breath • Exam: rapid heart rate, low blood pressure, friction rub • Tests: Diffuse ECG ST segment elevation, chest x-ray, echocardiography, chest CT • Treatment: treat underlying cause, NSAIDS, drain fluid with pericardiocentesis

  32. Pericarditis

  33. Temponade

  34. Esophageal rupture • Tear through the wall of the esophagus, allowing GI contents to leak into the mediastinum; usually occurs after significant vomiting or caustic ingestion • Older individual with known gastrointestinal problems. • History: Often recent violent emesis, foreign body, caustic ingestion, blunt trauma, alcoholism, esophageal disease; acute onset of localized pain • Exam: subcutaneous air (air in the soft tissue beneath the skin), decreased lung sounds • Tests: Chest x-ray, contrast esophagram, chest CT • Treatment: immediate antibiotics and surgery 90% mortality if not treated within 24 hours

  35. Esophageal Rupture

  36. Aortic Dissection • 1 per 100,000 population with a mortality rate exceeding 90% if misdiagnosed • Large arteries have three layers • If a tear occurs in the inner vessel wall, blood can track between the layers • Artery can rupture and dissection can progress • Decreased perfusion and massive bleeding • Location determines severity

  37. Aortic Dissection • History: Ripping/tearing chest/back pain radiating to the shoulder blade, may migrate, middle aged, high blood pressure, arterial disease • Physical: signs of blood loss (low BP, rapid heart rate), high blood pressure, ischemia, new murmur • Test: looking for markers, chest x-ray, and CT angiogram • Treatment: Medical management or surgery, depending on location and severity

  38. Aortic Dissection MRI CT Angiogram dcmrc.mc.duke.edu

  39. Aortic Dissection

  40. Heartburn • is caused by acidic fluid from the stomach washing up into the esophagus • a burning discomfort directly beneath the breastbone • often accompanied by burping, or symptoms of bloating or gas • sometimes an acid taste occurs in the mouth after a large meal, or after using tobacco, alcohol, or caffeine • symptoms tend to improve with antacids

  41. Benign Chest Wall Pain • a sharp "catch" that interrupts a breath, and that returns with each breath for a few moments - then it subsides • not related to exercise, and generally can be localized to a specific small area (smaller than the palm of the hand) on the chest wall • lasts for less than a minute, but can come back on and off for an hour or so • usually responds to analgesics

  42. When to Treat Chest Pain as an Emergency • patient is 40 years old or older, and have one or more risk factors for coronary artery disease (family history, smoking, obesity, sedentary lifestyle, elevated cholesterol, diabetes) • patient is of any age and have a very strong family history of early heart disease • the pain can best be described by the terms tightness, squeezing, heaviness, or crushing • the pain is accompanied by weakness, nausea, shortness of breath, sweating, dizziness or fainting

  43. the pain “radiates” to the shoulders, arms, or jaw • the pain is more severe than any the patient have had before • the pain is accompanied by the uncontrollable feeling that something is horribly wrong “impending doom” • the pain gets continually worse over the first 15 or 20 minutes • the pain is new – the patient has never experienced anything like it before

More Related