Nyeri Dada dalam Emergensi

Nyeri Dada dalam EmergensiPembimbing: dr. Aminah, SpJP30 Juli 2013

Kepaniteraan Klinik EmergensiPSPD FKIK UIN SH-RSUP Fatmawati

What is chest pain?Pain in the anterior thorax, from xiphoid to suprasternal notch and between the right and left midaxillary lines. Pain can be referred so adjacent areas are includedCharacter is variable tightness, pressure, stabbing, aching, burning, etc.

2Chest pain is a broad description. I am sure you have seen patients describe just about everything. Show on skeletonVisceral PainVisceral fibers enter the spinal cord at several levels leading to poorly localized, poorly characterized pain. (discomfort, heaviness, dull, aching)Heart, blood vessels, esophagus and visceral pleura are innervated by visceral fibersBecause of dorsal fibers can overlap three levels above or below, disease of thoracic origin can produce pain anywhere from the jaw to the epigastrum

3Parietal PainParietal pain, in contrast to visceral pain, is described as sharp and can be localized to the dermatome superficial to the site of the painful stimulus. The dermis and parietal pleura are innervated by parietal fibers.4Typical vs. Atypical Chest Pain

TypicalCharacterized as discomfort/pressure rather than painTime duration >2 minsProvoked by activity/exerciseRadiation (i.e. arms, jaw)Does not change with respiration/positionAssociated with diaphoresis/nauseaRelieved by rest/nitroglycerin

AtypicalPain that can be localized with one fingerConstant pain lasting for daysFleeting pains lasting for a few secondsPain reproduced by movement/palpationDifferential Diagnosis: What could it be?Cardiac:Myocardial ischemiaAcute myocardial infarction - Unstable angina - Stable angina ArrhythmiaAortic DissectionMyocarditis/PericarditisPulmonary:PleuritisPneumoniaPulmonary embolusPneumothorax

Gastrointestinal:EsophagitisEsophageal spasmGERDEsophageal rupturePancreatitisPeptic UlcerCholangitisCholecystitisCholedocholithiasis

Chest WallCervical disc diseaseCostochondritisHerpes ZosterNeuropathic painRib fractureArthritisPsychiatricAffective disorderAnxiety (panic attack)Somatiform disorders

6There are many causes of chest pain. When ever you think of pain you should think about what structures are in that area that could be the source of the pain.What information is available?HistoryPhysical ExamLaboratory TestsImaging Tests

If at any time you are concerned of a life threatening cause of chest pain, the proper treatment should be initiatedLow risk interventions have a lower threshold7When ever you are not sure what someone has you have a few ways to figure it out. Look at the pink form with me as we go.Chest pain historyDemographics:Age, sexChest Pain:Onset, DurationExacerbating and Relieving factorsExercise, positionCharacterLocationRadiation

Previous chest pain episodesAssociated symptomsCardiac risk factors and clotting risk factorsPast medical historyPrevious testing

Gives clues to cause of chest pain 8Certain age groups (younger not ACS but could be pulmonary embolism), females have lower incidence of ACS until after menopausehow long pain has been going on (ACS unlikely to be going on for 2 weeks straight), what makes it worse of better exacerbated by arm mvmtthink musculoskeletal; exacerbated by lying flat, esp after eatingconsider GERD; worse w/ exercise, relieved by resttypical for angina; relieved by leaning forwardthink pericarditiswhat type of pain: visceral vs. somatic pain, somatic is sharp and localized (chest wall)Radiation arm(s) is predictive of ACS; back more suggestive of aortic dissection or GI (pancreatitis, cholecystitis)had the symptoms before ex. Asthmatic can often identify typical attackwhat comes with it ex. SOB, n/v, sweating, lightheadedness are classic for ACS but may also be seen with other causesrisk factors cardiac includes HTN, DM, high cholesterol; clotting includes OCPs, inherited d/o, prolonged immobilityHistoryO- onsetP-provocation /palliationQ- quality/quantityR- region/radiationS- severity/scaleT- timing/time of onset9Physical ExamVital signsPulseTempBlood PressureRespiratory RateOxygen SaturationOverall patient appearanceNeck Veins (JVD)Cardiac auscultationMurmur, extra heart sounds

Lung AuscultationInfiltrates, lung volumes, effusion, wheezingLeg swellingChest wall or abdominal tenderness

Laboratory TestsMyocardial IschemiaMarkers of cell injury: creatine kinase, troponin, and creatine kinase-MBHeart Failure:B-type natriuretic peptide (BNP)Pulmonary embolismD-dimer

General Tests:Panel 7CreatineElectrolytesComplete Blood Count (CBC) Anemia, elevated WBCArterial blood gas (ABG)Ability to oxygenateAcid-base status

11These are some lab test that you may see ordered on patients presenting with chest pain. I will cover them further when I talk about each topic. Imaging TestsElectrocardiogram (ECG)Chest x-rayChest CT with or without contrastPE protocolDissection CT angiogramCoronary CT angiogramRadionuclide Perfusion Stress TestExercise, persantine, dobutamineCoronary catheterizationMagnetic resonance imaging/angiography (MRI/MRA)Echocardiography

12EKG Rhythm, Morphology (ST segment elevation, T wave inversion, etc)CXR - best for changes in the lung, chest wall and large masses; also gives a rough idea of cardiac size CT Chest can diagnose multiple conditions so it is versatile. Stress test evaluates perfusion of heart muscle relative to surrounding areasCoronary cath maps cardiac vasculature, identifies areas of narrowing/blockageMRI/MRA looks at soft tissue and can tell you about vasculature and small details (not good for moving things)Echo: ultrasound of heart, not good for really big people, operator dependent; during acute MI, may see that affected part of heart is not contracting properly; more useful in HF and valvular diseaseLife-Threatening CausesPulmonary embolusTension pneumothoraxPericarditis/cardiac tamponadeEsophageal ruptureAortic dissectionAcute myocardial infarction

Pericarditis with tamponadePericarditis is an infection of the tissues surrounding the heartInflammation causes build-up of fluid in the closed space around the heartHistory: hours to days of sharp chest pain, often positional (better when leaning forward), shortness of breathExam: rapid heart rate, low blood pressure, friction rub Tests: Diffuse ECG ST segment elevation, chest x-ray, echocardiography, chest CTTreatment: treat underlying cause, NSAIDS, drain fluid with pericardiocentesisPericarditis

Tamponade

16Note large, globular appearance of cardiac silhouette on CXROther common causesMusculoskeletal chest painMuscle strainCostochondritisArthritisTraumaPulmonaryPneumoniaAsthma/COPDSpontaneous pneumothoraxTumor

PsychiatricAnxietyGastrointestinalAcid reflux (GERD)Esophagitis/gastritis

Can often be evaluated by history, exam, response to medication, and chest x-rayTake Home PointsABCs firstHistory is keyHave a low threshold for missed MI

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