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Chest Pain

Chest Pain. Intern Report Curriculum. Five point approach. 1: ECG 2:History Most diagnoses are clear from a good history 3: Physical exam 4: CXR 5: Labs. Sick vs. Not Sick. Evaluate need for emergent care and associated emergent management

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Chest Pain

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  1. Chest Pain Intern Report Curriculum

  2. Five point approach • 1: ECG • 2:History • Most diagnoses are clear from a good history • 3: Physical exam • 4: CXR • 5: Labs

  3. Sick vs. Not Sick • Evaluate need for emergent care and associated emergent management • Guided by Focused History and Physical, along with ECG and chest radiograph • Awaiting labs may not be appropriate in emergent situations • If patients are sick and may need emergent intervention, always get your resident, fellow, etc. involved early!

  4. Let the patient describe symptoms – few will say “I’m having chest pain” Discomfort Heaviness Squeezing Pressure Tightness Burning Indigestion Quickly find out what chronic conditions the patient has: CAD CABG, PCI DM2 HTN PAD COPD GERD CKD History: listen to the patient!

  5. History: Questions to ask • #1: Are you having chest pain right now? (acuity) • Have you ever had pain like this before? (history) • When did the pain start? (timing) • What were you doing when the pain started? (association with activity) • How would you describe the pain? (quality)

  6. History: Questions to ask • How would you rate the pain (1-10)? (quantity) • Can you point to the pain? (location) • Does the pain go to your back, neck, or arm? (radiation) • Were there other symptoms that accompanied the pain? (SOB, diaphoresis, nausea, lightheadedness, palpitations) • Is there anything that makes the pain better or worse? (deep breaths, sitting up/lying down, SLNTG)

  7. Physical exam • Obtain vital signs and look at the patient • Respiratory distress, diaphoresis, alertness • Pulmonary exam • Crackles, wheezes, decreased breath sounds • Cardiac exam • Assess JVP! • Palpate carotids – note rate and rhythm • Palpate the precordium • Listen for murmurs and S3/S4

  8. Killip Classification for Acute MI

  9. ECG • Take at least 1 minute to read the entire ECG • Look for ST segment changes or new LBBB • Other clues: • T-wave inversion or peaking • Q waves (old MI) • Conduction abnormality (new BBB or AVB) • Axis deviation

  10. What is the diagnosis?

  11. LBBB (Beware of the new LBBB!)

  12. CXR • Systematic evaluation • Quick overview for glaring abnormalities • Technique • Skeleton (fractures, dislocations, lytic lesions) • Abdomen (diaphragm, stomach) • Airway/mediastinum • Heart size and shape • Lungs • Pneumothorax, infiltrates, edema, effusions

  13. Labs • Troponin • Most sensitive for cardiac damage • Repeat after 6-12 hours • CKMB • Helps determine timing of cardiac event • BNP? • Typically NOT useful for workup of chest pain • Others in case of urgent intervention • CBC, INR, PTT, BMP, beta-hCG

  14. Elevation of Cardiac Biomarkers http://www.publicsafety.net/image/graph.jpg

  15. Differential diagnosisWhat is your DDX forEmergent Chest pain?

  16. JAMA 1998; 280:1256-1268

  17. Emergent dx: tension pneumothorax • Absent breath sounds unilaterally • Respiratory distress • Tracheal deviation • Hypotension • NO TIME FOR CXR Tx: Immediate placement of large bore catheter needle @ 2nd intercostal space (midclavicular line)

  18. What is the diagnosis?

  19. Inferior STEMI

  20. Emergent dx: aortic dissection • Acute “tearing” chest pain radiating to the back • Usually hypertensive • Widened mediastinum • Differential arm BPs • Confirmed by CT chest (dissection protocol) or TEE (renal failure) • MRI: takes too long

  21. NO ENOXAPARIN NO HEPARIN NO CLOPIDOGREL Emergent cardiac surgery consultation Mortality is 1-2% per hour for Type A 50% die within 48h Esmolol drip – FIRST! Titrate to HR 60s Consider nitroprusside AVOID HYDRALZINE Emergent dx: aortic dissection

  22. What is the diagnosis?

  23. Anterior STEMI (Transmural)

  24. Emergent dx: STEMI • Immediately page CCU fellow • ASA 325 mg • NTG (SL then drip; remember SL more potent!) • Metoprolol (IV): goal HR 60s, SBP >100 • Heparin drip (anti-thrombin) • Plavix load-600mg • Pt needs recent CBC, PTT, INR, BMP • Ask about contrast allergy • Cath lab immediately (usually)

  25. What is the diagnosis?

  26. NSTEMI – Anterior Subendocardial Ischemia

  27. What portion of heart not seen well on ECG?

  28. Urgent dx: NSTEMI • Immediate goal: relieve angina • ASA 325 mg • NTG: SLNTG, then IV nitro if needed • If patient can not be made pain-free, may need cath lab • Metoprolol (goal HR 60s) • Heparin drip • Consider enoxaparin • GP IIb/IIIa inhibitor – usually Integrilin CAUTION • Clopidogrel – load with 600 mg PO x 1

  29. Immobilized pt (ortho?) Evidence for DVT Acutely SOB Hypoxemia High suspicion: PE protocol CT or VQ scan Low suspicion: check D-dimer and LE Dopplers If no contraindication and suspicion is high, begin treatment right away! IV heparin Consider enoxaparin Warfarin ICU if hemodynamically unstable Consider IVC filter if pt cannot be anticoagulated Urgent dx: pulmonary embolism

  30. What is the diagnosis?

  31. Acute Pericarditis!

  32. Other diagnoses • Acute pericarditis • Hypertensive urgency • Pneumonia • Esophageal disease (incl. GERD, esophageal spasm, Mallory-Weiss tear, Boerhaave’s syndrome) • Costochondritis • Other GI (gastric/peptic ulcers, pancreatitis) • Herpes zoster

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