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Emergency Medicine > Lecture 5: Chest Pain in the ED > Flashcards

Lecture 5: Chest Pain in the ED Flashcards

1
Q

What is the primary question to consider when someone presents with chest pain?

A

Is it cardiac or not?

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2
Q

What are the two types of chest pain in terms of nerve fiber?

A
  • Visceral: heart, vessels, esophagus, visceral pleura, often described as difficult to describe and localize
  • Somatic: Chest wall, from the dermis to parietal pleura, often described easily and precisely located
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3
Q

How does someone typically describe visceral chest pain?

A
  • Discomfort
  • Heaviness
  • Pressure
  • Tightness
  • Aching
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4
Q

How does someone typically describe somatic chest pain?

A
  • Sharp
  • Stabbing
  • Scratching
  • Non-radiating
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5
Q

What are the red flags that require immediate eval in triage?

A
  • Abnormal vitals
  • Concerning EKG findings
  • Hx prior CAD
  • Multiple ASCVD RFs: Age, HTN, tobacco use, HLD, DM, obesity, FHx, ASCVD, sedentary
  • Abrupt onset or severe or with DOE

Time is muscle!

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6
Q

Initial managment for chest pain in the ED

A
  • Bed
  • Cardiac monitoring + 2 IVs
  • EKG within 10 mins
  • Monitor/treat vitals

Keep O2 above 95% (for this course)

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7
Q

What are the 6 top DDx that present with chest pain?

A
  1. ACS
  2. Aortic Dissection
  3. PE
  4. Severe PNA
  5. Tension Pneumo
  6. Esophageal rupture

Alternative: PETMAC for 6 most deadly causes of chest pain
PE
Esophageal rupture
Tension Pneumo
MI/ACS
Aortic Dissection
Cardiac Tamponade

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8
Q

4 Primary DDx that present with visceral pain

A
  • Unstable angina
  • MI
  • Aortic Dissection
  • Esophageal rupture
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9
Q

3 Primary DDx with present with pleuritic chest pain

A
  1. PE
  2. PNA
  3. Spontaneous Pneumo
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10
Q

What is important to keep in mind when doing an EKG?

A

It does not r/o ACS or life-threatening causes of chest pain.

Do serial if pt still in pain but EKG was normal.

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11
Q

First-line cardiac enzyme lab

A

Troponins, which elevate as quickly as 4h.

I & T are the troponins we measure.

Trops have 100% specificity!
Peaks in 24-48h remaining elevated for days.

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12
Q

Pitfall of troponins

A

Not reliable in detection of re-infarction

It takes a while for it to go back down!

Use CK-MB instead, which normalizes in 48-72h.

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13
Q

When is emergent echo indicated?

A
  • Aortic dissection if not CTA available
  • Cardiac tamponade

You need a very skilled US person + someone that can interpret it.

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14
Q

How do we determine to admit for chest pain?

A

HEART scoring, which determines MACE in the following 6 weeks (Major adverse cardiac event)

Elkins said just know the score ranges at the bottom.

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15
Q

Minimum HEART score for admittance? Invasive therapy?

A
  • Admittance: 4-6
  • Invasive: 7-10

0-3 = discharge byebye

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16
Q

What is HTN crisis?

A
  • SBP >180
  • AND/OR
  • DBP > 120
17
Q

HTN urgency vs HTN emergency

A
  • Urgency = HTN crisis without end-organ damage
  • Emergency = HTN crisis with end-organ damage
18
Q

What are the 5 end-organs?

A
  • Brain
  • Heart
  • Aorta
  • Kidneys
  • Eyes
19
Q

What signs suggest HTN retinopathy?

A
  • Papilledema
  • Flame-shaped hemorrhages
  • Macular exudates
  • Cotton-wool spots
20
Q

DOC for treating HTN urgency with no hx of HTN

A

HCTZ daily

21
Q

Management of BP in HTN emergency

A
  1. IV antiHTNs
  2. Reduction of SBP by a max of 25% in the first hour (3 exceptions)
  3. If stable, reduce to 160/100 over 2-6 hours, then normal.

The 3 exceptions to lowering SBP by 25%:
Aortic dissection
Acute ischemic stroke
ICH

22
Q

If a patient is having pre-eclampsia and HTN emergency, what is the go-to IV AntiHTN?

A

Hydralazine

23
Q

For a patient with renal insufficiency in HTN emergency, what is the DOC?

A

Fenoldopam

D1 receptor agonist, unique

24
Q

For a patient with aortic dissection, what are the two primary DOC for lowering BP?

A
  • Esmolol
  • Labetalol
25
Q

Features of esophageal rupture/Boerhaave syndrome

A
  • Tear/rupture of distal (MC) 1/3 of esophagus, causing pneumomediastinum
  • MCC: forceful vomiting/coughing
  • Posterolateral wall of distal esophagus (90% of cases)
26
Q

How does someone with esophageal rupture present?

A
  • Sudden onset substernal chest pain post vomiting episode
  • Radiation into neck or abd, worsened by neck flexion, breathing, and swallowing
  • Fever/diaphoresis/SOB/Tachycardia/subcutaneous emphysema
27
Q

What is Hamman’s crunch/sign?

A

Mediastinal crunch (rice krispies) under the apex of the lung.

Subcutaneous emphysema; seen in Boerhaave syndrome

28
Q

What can be seen on CXR for esophageal rupture?

A
  • Pneumomediastinum
  • Pneumoperitoneum
29
Q

Management of Esophageal rupture

A
  1. Airway
  2. NPO/IVF
  3. ABX: Unasyn or Zosyn (Clinda + cipro)
  4. NG/OG tube
  5. Surgery consult
30
Q

What does cardiac tamponade affect specifically in the heart?

A

Affects the right side of the heart

R side is lower than L slightly

31
Q

Why does hypovolemia cause cardiac tamponade to develop slower?

A

Hypovolemia lowers ventricular filling pressure

32
Q

Clinical presentation of cardiac tamponade

A
  • DOE and rest
  • Tachycardia
  • Hypotension with narrow PP
  • Pulsus paradoxus (Drop of SBP > 10-20 during inspiration)
  • JVD
  • Distant heart sounds
33
Q

What is Becks’ triad?

A
  1. Hypotension
  2. JVD
  3. Decreased heart sounds

Cardiac tamponade

34
Q

Most sensitive and specific diagnostic tool for cardiac tamponade?

A

TTE

35
Q

EKG findings suggest of cardiac tamponade

A
  • Lower voltage QRS
  • Electrical alternans
  • Diffuse STE (pericarditis as underlying cause)
36
Q

CXR finding for cardiac tamponade

A

Enlarged cardiac silhouette

37
Q

Emergent procedure for unstable cardiac tamponade

A

Pericardiocentesis

Emergency Medicine (29 decks)

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