Emergency lectures - Chest pain
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Transcript of Emergency lectures - Chest pain
Chest Pain
Hugh Hemsley MDRiverside Regional Medical CenterVirginia, USAFebruary 2011
Chest PainCardiovascular disease is the number 1 cause
of death in the United States5.4% of all visits to the ED are for chest painEtiology can be difficult to diagnose
Includes diseases of the chest and abdomenDiseases can vary from benign to life-
threateningDifferent diseases can present with similar
signs and symptoms
Evaluation of Chest PainGOAL-Early detection and safe management
of life-threatening diseasesComplete history is very importantTimely and appropriate testingDo not focus on a benign disease and miss a
life-threatening illness
Chest Pain2.5% of patients with an acute MI are sent
home 20% of all ED malpractice claims are for
misdiagnosed chest pain complaints.
Chest PainWhy do diseases of different organ systems
present with similar symptoms?Visceral versus somatic pain
Visceral PainSensory nerves from internal organs enter
the spinal cord at multiple levels and thus the pain is difficult to describe and localizeAching, pressure, heaviness
Somatic PainBone, skin, muscle, parietal pleuraSensory nerves from these structures enter
the spinal cord at specific levels and the pain is easily described and localizedSharp, stabbingPatients will point to an area of well localized
pain
Causes of chest pain Cardiovascular
A.C.S. Pericarditis Aortic dissection Aortic stenosis
Pulmonary Pulmonary embolism Pleurisy Pneumothorax Pneumonia
Pediatrics Kawasaki disease Hypertrophic cardiomyopathy Congenital heart disease
Gastrointestinal Esophageal reflux Esophageal spasm Esophageal rupture Peptic ulcer disease Gallbladder disease Pancreatitis
Chest Wall Pain Herpes Zoster Costochondritis Cervical radiculopathy Rib fracture Anxiety
Evaluation of chest painMaintain a high index of suspicion for life-
threatening illness in all patients complaining of chest pain.
Rapid triage of all patients complaining of chest pain
Is the patient at risk for serious illness?Abnormal vitals signsPatient looks sick, diaphoretic, short of breath,
altered level of consciousness.Risk factors or history of cardiovascular
disease Cardiac monitor, IV, oxygen EKG within 10 minutes of patient arrival
HistoryComplete history most importantFocus on the characteristics of the pain,
associated symptoms, risk factors, and history of cardiovascular disease
Pain scale 1-101-no pain10-worst possible pain
HistoryDuration of the pain
Pain lasting seconds probably not cardiacConstant pain for longer than 8-12 hours with
negative workup probably not cardiac
Intensity of painImmediate onset of severe pain think aortic
dissectionACS pain gradually reaches maximum intensity
HistoryQuality of the pain
Burning pain more likely gastrointestinalTearing pain typical of aortic dissectionSharp, stabbing pain usually not ischemic
Up to 20% of patients with an acute MI describe pain as sharp
Pleuritic pain-worse with breathing or coughing Lung, musculoskeletal, pericardial Pleuritic chest pain is described in up to 6% of MI
patients.
HistoryChest wall pain-well localized pain reproduced
by movement or palpation of the affected areaACS-visceral pain radiates to the jaw, arms,
and neckACS-associated symptoms
Shortness of breath, nausea, diaphoresis, fatigue, vomiting, palpitations
Risk factorsAge > 40MalePost-menopausal femaleHypertensionHyperlipidemiaCigarette smokingDiabetesFamily historyObesityDrug abuse-cocaine
The absence of risk factors does not rule out cardiac disease
Acute Coronary SyndromeACSUnstable Angina
New onset of symptomsSymptoms that occur at restA change in the patient’s usual pattern of anginaNo ST elevation, no elevation of cardiac enzymesEKG will be normal about 50% of patientsEvidence of ischemia-ST depression or T-wave
inversion
ACSAcute Myocardial Infarction
STEMI ST elevation of >1 mm in at least 2 contiguous
leads Elevated cardiac enzymes
Non-STEMI ST depression and T wave inversion New left bundle branch block or Q waves Elevation of cardiac enzymes
STEMI-ST elevation MI
Non-STEMI
ACSPain starts following exertion, eating, exposure to cold or emotional stress, can occur at restPressure, heaviness, tightness, squeezing,
“an elephant is sitting on my chest”
Pain radiates to the shoulders, arms, or jawAssociated symptoms-diaphoresis, shortness
of breath, nausea, vomiting, weakness palpitations
Anginal EquivalentsAtypical Chest PainUp to 33% of ACS will not have chest pain
Dyspnea with exertion or at restShoulder, arm, or jaw pain onlyNauseaLightheaded, dizzy, or syncopeGeneralized weaknessDiaphoresisAcute change in mental statusPalpitations
Anginal equilavents are more common in females, diabetics, and the elderly
EKGThe best test to rapidly diagnose an acute MIObtain within 10 minutes of patient’s arrival Up to 50% of initial EKGS will be normal or
have non-diagnostic changesSerial EKGS
BiomarkersTroponin T and I
Preferred markerProtein located in cardiac musclePoor sensitivity first 6 hours after onset of symptomsRepeat in 8-12 hours after onset of symptomsCan be elevated with
Pulmonary embolism Aortic dissection Renal failure Sepsis Cardiac trauma or surgery CHF
BiomarkersCPK
Located in cardiac and skeletal muscleCPK/MB is the cardiac isoenzymePoor sensitivity first 6 hours after onset of symptomsRepeat testing in 8-12 hoursUseful in detecting reinfarction
MyoglobinFound in skeletal and cardiac muscleGood sensitivity early after onset of symptoms
but poor specificity
BiomarkersTest Onset Peak
Duration
CPK/MB 3-12 hours 18-24 hours36-48 hours
Troponin 3-12 hours 18-24 hoursUp to 10 days
Myoglobin 1-4 hours6-7 hours 24 hours
Repeat in 8-12 hours
Pulmonary EmbolismMajority form in the deep veins of the pelvis
and lower extremitiesSize of the clot will determine signs and
symptomsLarge clots can cause syncope, abnormal
vitals, sudden death
Pulmonary EmbolismRisk factors
Previous DVT or PEPregnancyCancerRecent surgeryProlonged bed restAge>50SmokingOral contraceptivesObesityInherited blood disorders
Pulmonary EmbolismSigns and symptoms
DyspneaPleuritic chest painTachycardiaCoughHemoptysisCoughFever rarely >102SyncopeEvidence of DVT in the extremities
Pulmonary EmbolismEKG-obtain to rule out cardiac etiology
Sinus tachycardiaNon-specific ST and T wave changesRight heart strain pattern RBBB
Chest x-ray-obtain to rule out other causesUsually normal or non-specific changes
Arterial blood gas-ABGNot useful in the diagnosis of a PECan have a normal PO2 and A-a gradient with PE
Pulmonary EmbolismD-Dimer
Fibrin degradation productTest sensitivity 95%, specificity low 50%What can elevate the D-Dimer
Pregnancy Cancer Trauma Recent surgery Disseminated intravascular coagulation DIC
Pulmonary EmbolismNegative D-Dimer and “low risk” no further
testing neededWho is “low risk”?
Well’s CriteriaSimplified Geneva ScorePERC score
High risk patients-Do not obtain a D-Dimer immediately to go other testingCT ScanV/Q ScanPulmonary angiogram
PericarditisInflammation of the pericardial sacPain is due to irritation of the parietal pleuraSharp pleuritic substernal pain
Radiates to the back, neck, or shoulderWorse with cough, inspiration, supineImproves with leaning forward
Pericardial friction rub, tachycardia, dyspneaEKG-diffuse ST elevationTroponin is elevated in up to 22%
Pericarditis EKG
Spontaneous PneumothoraxSudden rupture of a lung bleb
Tall thin males age 20-40Underlying lung diseaseSmokers
Sudden onset of sharp pain, worse with inspiration, and SOB
Physical exam-decreased breath sounds on the affected side
Tension pneumothorax-Immediate life threatDecreased venous return to the heartSevere respiratory distress, tachycardia, hypotension
Pneumothorax
Tension Pneumothorax
Aortic DissectionStarts as a tear in the intima of the aorta that spreads through
the medial wall under elevated systolic aortic pressure
Mortality untreated28% in 24 hours50% in 48 hours70% in one week
Risk factorsHypertensionPregnancyLupus, syphilis, endocarditisMarfan’s disease
Aortic DissectionSigns and Symptoms depend on the location of
the tear and involvement of the aortic root, coronary ostia, or branches of the aorta
HistorySudden onset of sharp, tearing, maximal painPain radiates to the neck or back
Aortic DissectionPhysical exam
Majority will be hypertensiveDifference in blood pressure between armsMurmur of aortic regurgitation Neurologic deficits
Chest pain with neurologic deficit, THINK DISSECTION
EKG-useful to rule in or out MIChest Xray
Widened mediastinumRule out other etioloiges
Aortic Dissection
Gastrointestinal Etiology in up to 40% of chest pain
complaintsDifficult to discern from ACSPain described as burning, pressure, or dullAcid Reflux
Substernal, epigastric burning painPain worse with alcohol, caffeine, certain foodsWorse supine and in the morningRelieved with antacids
GastrointestinalEsophageal spasm
Often associated with reflux diseaseDull, pressure, substernal pain lasting for
hoursCan be relieved with Nitroglycerin
NTG relaxes smooth muscles Pain relief with NTG NOT diagnostic of ACS
Peptic ulcer diseasePancreatitis and gallbladder disease
Include lipase and liver function tests in your workup
Boerhaave’s SyndromeForceful vomiting after excessive eating and
drinking causes esophageal rupture.Mediastinal contamination of stomach
contentsSudden onset of severe pain radiating to the
backMortality is 10-50% and directly related to
the delay in making the diagnosis and initiating treatment
Boerhaave’s Syndrome
Chest Wall Pain The cause in up to 30% of ED visitsWell localized, sharp, positional painReproducible by palpating a specific area of
the chest wallCostochondritis-pain and tenderness at the
costochondral or costosternal jointsTreat with rest, heat, NSAID
Mental IllnessThe cause in up to 10% of ED visitsPatients are poor historians with vague
symptomsHyperventilation can cause non-specific ST-T
wave changesA diagnosis of exclusion
Chest PainCervical disc disease
Nerve root compression causes chest pain
Herpes ZosterSharp burning pain before the rashPain and herpetic rash in a dermatome
distribution
Herpes Zoster
Thank you