Chest Pain Non Trauma

8/13/2019 Chest Pain Non Trauma

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Chest Pain

(Non - Trauma)Oleh :

M. Samsul Arifin 0810710072

Nur Hidayati Azar 0810710088

Peppy Tria 0810710092Tita Luthfia S 0810710107

Anantika Putri 0810713004

Arrasyid Indra 0710713025

Pembimbing :

dr. Munsifah Z., SpEM

FK UNIV. BRAWIJAYA/RSU DR. SAIFUL ANWAR

MALANG2013


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Introduction

Chest painmany

symptoms overlap

Goal in ED is to r/o life

threatening causesof chestpain

Need appropriate history,

physical exam, and ancillary

tests


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LIFE-THREATENING CAUSES

Acute myocardial infarction

Unstable angina

Aortic dissection

Pulmonary embolism

Tension pneumothorax

Oesophageal rupture


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NON LIFE-THREATENING CAUSES

Cardiac Stable angina

Prinzmetal angina

Pericarditis/myocarditis

Respiratory Simple pneumothoraxPneumonia with pleurisy

Gastrointestinal Reflux oesophagitis

Oesophageal spasm

Referred pain Gastritis/PUD

Biliary disease

Subphrenic abscess/inflammation


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Time & character ofonset

Quality

Location Radiation

Associated Symptoms

Chest Pain - History

Aggravating symptoms

Alleviating symptoms

Prior episodes

Severity Review risk factors


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Time & Character of Onset

Abrupt onset with greatest intensity at start :

Aortic dissection, PTX, Occasionally PE will present in this

manner

Chest pain lasting seconds or constant over weeks is not

likely to be due to ischemia

Pleuritic Pain: PE, Pleurisy, Pneumonia, Pericarditis, PTX

Esophageal: Burning

MI: squeezing, tightness, pressure, heavy weight on chest,

can also be burning

Sharp, tearing, ripping pain: Aortic Dissection

Quality


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If very localized, consider chest wall pain or pain of pleural

origin

Location

Associated Symptoms

Fevers, chills, URI symptoms, productive cough : Pneumonia Nausea, vomiting, diaphoresis, shortness of breath: MI Shortness of breath: PE, PTX, MI, Pneumonia, COPD/Asthma Asymmetric leg swelling: DVTPE

With new onset neurologic findings or limb ischemia:consider dissection Pain with swallowing, acid taste in mouth: Esophageal

disease


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Activity: Consider ischemic heart disease Food: Consider esophageal disease

Position: If worse with laying back, consider pericarditis.

Swallowing: Esophageal disease

Movement: Chest wall pain Respiration: PE, PTX, Pneumonia, pleurisy

Palpation: Chest Wall Pain

Aggravating Symptoms


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Alleviating Symptoms

Rest/ Cessation of Activity: Ischemic Sitting up: Pericarditis

Antacids: Usually GI system

Prior Episodes

Have they had this kind of pain before Does this feel like prior cardiac pain, esophageal pain, etc

What diagnostic work-up have they had so far? Last ECG,echo, last stress test, last cath, etc


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Risk Factor

Hypertension, DM, high cholesterol, tobacco, family history Long plane trips, car rides, recent surgery or immobility,

hypercoagulable state: PE

Uncontrolled HTN/ Marfans: Dissection

Rheumatic Diseases: Pleurisy Smoking: COPD, Ischemia

Severity

Severity of chest pain


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Chest PainPhysical Examination

Review vital signs* Fever: Pericarditis, Pneumonia

* Check BP in both arms: Dissection

* Decreased sats: More commonly in pneumonia, PE, COPD

* Unexplained sinus tachy: consider PE

Neck

* Look for tracheal deviation: PTX

* Look for JVD: Tension PTX, Tamponade, (CHF)

* Look for accessory muscle use: Respiratory Distress(COPD/ASTHMA)


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Chest wall exam* Look for lesions: Herpes Zoster

* Palpate for localized tenderness: Likely musculoskeletal cause

Lung exam* Decreased breath sounds/hyperresonance: PTX

* Look for Rhonchi: Pneumonia

* Listen for wheezing/prolonged expiration: COPD


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Cardiovascular Exam* Assess heart rate

* Listen for murmurs, S3/S4

* Pericardial friction rub: pericarditis

* Muffled heart sounds: Tamponade* Assess distal pulses

Abdominal Exam

* Assess RUQ and epigastrium

NEURO EXAM

* Chest pain +neurologic findings: consider dissection


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Chest PainAncillary Tests

LABS CBC, PT/PTT, D dimer (PE), Blood cultures(pneumonia), Sputum cultures (pneumonia), Peakflow (Asthma), ABG, Cardiac Enzymes (MI), ESR(pericarditis)

CXR - Rib fractures

- Hamptons Hump/Westermarkssign: PE

- Infiltrates: Pneumonia

- Widened mediastinum: Aortic dissection

- Pneumothorax

- Cardiac size: enlarged silhouette without CHF:pericardial effusion

ECG MI

CT Scan CT Scan Thorax if suspect PE or Aortic Dissection


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Management Non Traumatic

Chest Pain

Ensure vital sign are stable. If unstable, patient in distress

and diaphoretic, bring patient to resuscitation area

immediately

Put patient on oxygen supplementation, pulse oximetry,continuous ECG monitoring, blood pressure monitoring

Set up IV line and take blood test

Give pain relief depending on provisional diagnosis


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ACUTE MYOCARDIAL INFARCTION (AMI)

Definisi

Sering disebut serangan jantung, merupakan akibat darigangguan aliran darah ke bagian jantung, menyebabkan

kematian sel jantung mati.

Tanda dan Gejala

Nyeri dada tiba-tiba (menyebar ke lengan kiri atau lehersebelah kiri), sesak nafas, nausea, vomiting, palpitasi,berkeringat, dan cemas.


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Management AMI

O2Aspirin 300-

320 mgCPG 300

mg

S/L GTN 1 tabstat, repeatECG after 5minutes (to

exclude ECGchanges dtcoronary

spasm)

Morphine iv

2-5 mgslow bolus

(ifnecessary)

IV GTN 20-200microgram/min, increase by 5-

10microgram/min

at 5-10 minintervals (ifnecessary)

Considermyocardial

salvagetherapy

Considerthrombolytic

therapy


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Indikasi Terapi Thrombolytic

Typical chest pain of AMI

ST elevation of at least 1 mm in at least 2 inferior ECG

leads or elevation of at least 2 mm in at least 2

contiguous anterior leads

< 12 h from chest pain onset

< 75 y.o of age


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UNSTABLE ANGINA PECTORIS

Unstableanginaresults

from thesudden

rupture of aplaque

Rapidaccumulationof platelets at

the rupturesite and asudden

increase inobstruction toblood flow inthe coronary

artery

Accumulation

of plateletsandobstruction toblood flow can

result in aheart attack

Risk of heartattack remains

even if theunstableangina

symptomslessen ordisappear


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Tanda dan Gejala UAP

Bisa berlangsung selama 5-20 menit. Gejala yang dirasakan :

Nyeri atau tertekan

Rasa berat dan tidak nyaman pada dada, leher,

kerongkongan, bahu dan lengan

Rasa terbakar atau indigestion Sesak

Unstable angina terjadi tanpa didahului tanda awal dan

terjadi saat istirahat sehingga sering mengakibatkan ansietas.

Gejala lain yang bisa terjadi : Mual

Nyeri kepala

Keringat berlebihan


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Management UAP

Nitrates

- Dilatasi pembuluh darah

- Mengurangi resistensi pembuluh darahmengurangi

kerja jantung (workload) Beta-blockers

- Memperlambat denyut jantung dan mengurangi tekanan

kontraksi otot jantung

Calcium channel blockers

- Dilatasi pembuluh darah dan mengurangi tekanan darah


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PULMONARY EMBOLISM (PE)

PE is a blockage of themain artery of the lungor

one of its branches by a

substance that has

travelled from elsewherein the body through the

bloodstream (embolism)

Origin >> DVT

Virchows Triad(Endothelial Injury, Stasis,

Hypercoagulability)
http://en.wikipedia.org/wiki/Pulmonary_arteryhttp://en.wikipedia.org/wiki/Embolismhttp://en.wikipedia.org/wiki/Embolismhttp://en.wikipedia.org/wiki/Pulmonary_artery


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Clinical Symptoms of PE

Clinical symptoms suggestive of PE: Dyspnea

Chest pain (Pleuritic/non pleuritic)

Cough

Orthopnea Calf and/or thigh pain or swelling

Wheezing

Common signs:

Tachypnea

Tachycardia

Rales

Decreased breath sounds Jugular venous distension

Accentuated pulmonic

component of second

heart sound

Symptoms/ signs of lower extremity DVT include :

edema, erythema, tenderness or a palpable cord.


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PE Management

Initiate Heparin- Unfractionated Heparin: 80 Units/Kg bolus IV, then

18units/kg/hr

- Fractionated Heparin (Lovenox): 1mg/kg SubQ BID

- If high pre-test probability for PE, initiate empiric heparinwhile waiting for imaging

- Make sure no intraparenchymal brain hemorrhage or GI

hemorrhage prior to initiating heparin.

Consider Fibrinolytic Therapy:

- Especially if PE + hypotension


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PE Management

Surgery and Other Prosedure Consider Clot removal. For a very large clot in lung and in

shock, doctor may thread a thin flexible tube (catheter)

through blood vessels and suction out the clot.

Vein filter.Filter insertion is typically reserved for peoplewho can't take anticoagulant drugs or when anticoagulant

drugs don't work well enough

Surgery.IThis happens infrequently, and the goal is to

remove as many blood clots as possible, especially if there'sa large clot in main (central) pulmonary artery.


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AORTIC DISSECTION

Aortic dissection is an acute event where blood enters

the aortic wall through a tear of the intima followed by

extravasation of blood into the media.

Currently believed the process begins with an intramuralhematoma


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Etiology

Degenerative

Hypertension

Pregnancy

Skeletal (scoliosis) Connective tissue (Marfans)

Mycotic aneurysm

Takayasu (giant cell) arteritis

Aortic laceration/coarctation


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Aortic Dissection

Stanford Classification

Type A -involves ascending

aorta

Type Binvolves

descending aorta

DeBakey Classification

Type Iascending, arch &

descending aorta

Type IIascending only

Type IIIdescending only


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Aortic Dissection

ClinicalFeatures

>85%abrupt,

severe painin chest or

b/wscapula

50%ripping or

tearing

Pain inanteriorchest

ascendingaorta (70%)

Back pain(less

common)descendingaorta (63%)

Ifdissection

into carotidclassic

neurosymptoms


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Aortic Dissection

Physical Exam

Usually normal heart and lung exam

May have aortic insufficiency


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Aortic Dissection

T

reathype

rtension-blocker

Esmolol 500g/kgIV bolus over 1minute then 50-

150 g/kg minute

Metoprolol 5mgq2min x3 IV then 2-5mg/hr

Propranolol 20mgIV then 40mg, 8-mg q10min to

300mg totalCalcium channel

blocker if -blockercontraindicated

Va

sodilatorNitroprusside 0.3

g/kg/min IV

SurgeryOR for ascending

aortic dissection

Descending aorticdissection worsesurgical risks

controversial forrepair


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Trachea deviates to contralateral side

Mediastinum shifts to contralateral side

Decreased breath sounds and hyperresonance on affectedside

JVD

Treatment: Emergent needle decompression followed bychest tube insertion

TENSION PNEUMOTHORAX


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NEEDLE DECOMPRESSION

Insert large bore needle (14 or 16 Gauge) with catheter inthe 2nd intercostal space mid-clavicular line. Removeneedle and leave catheter in place. Should hear air.


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Nyeri dada pleuritik

Lokasinya posterior atau lateral. Sifatnya tajam dan

seperti ditusuk.

Bertambah nyeri bila batuk atau bernafas dalam dan

berkurang bila menahan nafas atau sisi dada yang sakit

digerakan.

Nyeri berasal dari dinding dada, otot, iga, pleura

perietalis, saluran nafas besar, diafragma, mediastinum

dan saraf interkostalis.


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Nyeri dada Non- pleuritik

Lokasinya sentral, menetap atau dapat menyebar ke

tempat lain.

Sering disebabkan oleh kelainan di luar paru.


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Nyeri Dada

Non

Pleuritik

Kardial

Perikardial

Aorta

Muskulo

skleletal

Fungsional

Pulmonal


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Trauma lokal atau radang dari rongga dada otot, tulangkartilago sering menyebabkan nyeri dada setempat.

Nyeri biasanya timbul setelah aktivitas fisik.

Muskulo

skeletal

Kecemasan dapat menyebabkan nyeri substernal atauprekordinal, rasa tidak enak di dada, palpilasi, dispnea,using dan rasa takut mati.

Fungsional

Obstruksi saluran nafas atas seperti pada penderitainfeksi laring kronis dapat menyebakan nyeri dada,terutama terjadi pada waktu menelan.

Pada emboli paru akut nyeri dada menyerupai infarkmiokard akut dan substernal.

Nyeri dada merupakan keluhan utama pada kanker paruyang menyebar ke pleura, organ medianal atau dindingdada.

Pulmonal


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Angina stabil (Angina klasik, Angina of Effort), Angina takstabil (Angina preinfark, Insufisiensi koroner akut) ,Infark miokard

Kardial

Saraf sensoris untuk nyeri terdapat pada perikardiumparietalis diatas diafragma. Nyeri perikardila lokasinya di

daerah sternal dan area preokordinal, tetapi dapatmenyebar ke epigastrium, leher, bahu dan punggung

Nyeri bisanya seperti ditusuk dan timbul pada aktumenarik nafas dalam, menelan, miring atau bergerak.

Perikardial

Penderita hipertensi, koartasio aorta, trauma dindingdada merupakan resiko tinggi untuk pendesakan aorta.

Diagnosa dicurigai bila rasa nyeri dada depan yang hebattimbul tiba- tiba atau nyeri interskapuler

Aorta


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Chest Pain Non Trauma

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