Acute Chest pain

Question 1

5 main causes of chest pain

Answer 1

1. ACS
2. PE
3. Aortic dissection
4. Pneumonia
5. Pneumothorax

Question 2

PE symptoms

Answer 2

1. acute onset 2. Sharp chest pain 3. Breathlessness 4. Calf pain 5. Tachycardia

Question 3

Well’s criteria

Answer 3

1. Haemoptysis 2. Malignancy 3. Previous DVT/PE 4. Heart rate > 100 beats per minute 5. Surgery 6. Suspected DVT

Question 4

Initial Ix for chest pain

Answer 4

• appearance
• vital signs
• ECG
• CXR
• troponin
• ABG
• D - dimer

Question 5

ECG for PE (textbook example)_

Answer 5

SIQ3T3

• S waves in lead I
• Q waves in lead III
• Inverted T waves in lead III

Question 6

Treatment for PE

Answer 6

1. Shocked - thrombolysis 2. Anticoagulants to halt clot progression and allows fibronlysis

Question 7

Aortic dissection

Answer 7

a serious condition where there is a tear in the intima of the aorta. 2. blood flow in the inner and outer layers of the media

Question 8

Types of aortic dissection

Answer 8

1. Ascending aorta 2. Arch of the aorta and descending 3. Descending aorta

Question 9

What patients may have MI but no chest pain?

Answer 9

• elderly
• diabetic

*due to autonomic dysfunction

Question 10

Typical SOCRATES in Hx of patient with MI

Answer 10

Question 11

Changes on ECG that classify as STEMI MI

Answer 11

Question 12

Pericarditis changes on ecg

Answer 12

Smiley, upsloping ST segments

Question 13

Changes on ECG associated with cocaine use

Answer 13

• high take-off
• vasospasm is common

Question 14

ECG changes in a cardiac infarction

Answer 14

Question 15

What ‘J point’ is used for?

Answer 15

• Look at J point to assess how much higher or lower from a base line
• the J point (to assess for ST elevation)

Question 16

Regions ECG

Answer 16

Question 17

What is it suggestive of:

Elevated troponin + chest pain + suggestive ECG changes

Answer 17

MI

Question 18

Treatment of acute ST elevation MI

Answer 18

• Oxygen -> only when needed (depends on sats)
• Nitrates -> to vasodilate the arteries
• Symptomatic treatment with opiates and antiemetics -> if needed
• Anti-platelet etc - to prevent clots from spreading

Question 19

Is troponin elevated in:

A. unstable angina

B. Non-STEMI

Answer 19

A. Unstable angina - troponin is normal

B. Non-STEMI - troponin is elevated

Question 20

Changes on ECG suggestive of transmural ischaemia

Answer 20

ST elevation

Question 21

Changes on ECG suggestive of subendocardial ischaemia

Answer 21

• ST depression
• T inversion

Question 22

What’s the tool to assess the likelihood of a chest pain being cardiac?

+ meaning

Answer 22

• 0-3 = low risk (<2%)
• 4 - 6 = medium risk (12 - 17%)
• 7-10 = high risk (50 - 65%)

Question 23

Treatment for unstable angina/Non-STEMI

Answer 23

Question 24

Typical SOCRATES (Hx) in PE

Answer 24

Question 25

Signs on examination of a pt with PE

Answer 25

Question 26

Investigations in PE

Answer 26

Question 27

Treatment of PE

Answer 27

• if shocked -> thrombolyse

• if not shocked -> anti-coagulate (to stop clot progression and allow fibrinolysis)

Question 28

SOCRATES (on Hx) of a patient with aortic dissection

Answer 28

Question 29

Signs and symptoms in aortic dissection

Answer 29

Question 30

Investigations in aortic dissection

Answer 30

• CT - gold standard
• CXR
• ECHO
• TOE (transoseophageal ECHO)

Question 31

Treatment for aortic dissection

Answer 31

Surgery

Question 32

Characteristic of chest pain in pneumothorax

Answer 32

• chest pain
• worse on inspiration (usually)
• sharp
• can be mild or severe

Question 33

Differences of tension vs non-tension pneumothorax on x-ray

Answer 33

tension - mediastinum is pushed to the sie

Question 34

Ix for pneumothorax

Answer 34

• Vital signs - may show signs of shock
• Auscultation - may hear reduced air entry on that side (may not)
• Hyper-resonant affected side
• CXR
• US -> to confirm if any doubt