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Chest Pain Flashcards

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1
Q

Leading cause of sudden death in US

A

AMI

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2
Q

6 life-threatening causes of chest pain

A 
AMI/unstable angina
Aortic dissection
Pulmonary Embolus
Spontaneous pneumothorax
Esophageal rupture (Boerhaave's syndrome)
Pericarditis/pericardial tamponade
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3
Q

Most specific associated symptom to AMI

A

Diaphoresis. Sweat if your pt sweats!!

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4
Q

Classic RFs for CAD

A 
Male
Smoker
Diabetes
HTN
Age>55
Hyperlipidemia
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5
Q

Conditions that cause inflammation that are a RF for CAD

A

Cocaine abuse
Lupus
HIV
Chronic Kidney Disease

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6
Q

AMI signs on EKG

A

ST segment elevation
Q waves
ST segment depression
Inverted T waves

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7
Q

Most common cardiac enzymes measured

A

Myoglobin, troponin, CPK
used to determine if CP admission requires ICU
Negative in unstable angina–take a few hrs after injury to become +
Need to repeated at intervals

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8
Q

Common Radiology tests

A

CXR–MOST USEFUL. standard part of CP eval
ECHO-wall motion abnormalities in ischemia
CT scan–pulmonary embolism, aortic dissection, esophagus rupture
Esophagram–esophageal rupture

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9
Q

Stress tests–useful in? what does it show?

A

useful in selected low-risk ED patients

shows ischemia, motion abnormalities

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10
Q

Therapeutic treatment

A

Nitroglycerin
GI cocktail
NSAIDs

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11
Q

Common Hx of AMI

A

Pressure, tightness sensation in chest or indigestion
Radiation to jaw, shoulder, neck common
Diaphoresis, nausea, dyspnea
Lasts longer than 15-30 min
Pain at rest, or precipitated by exertion

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12
Q

Common PE of AMI

A

Pt appears anxious, restless, uncomfortable
Pallor & diaphoresis common
brady or tachycardia possible
EXAM OFTEN NORMAL

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13
Q

EKG findings for AMI

A

Hyperacute T waves common early<30 min
ST segment elevation=injury
Look for reciprocal ST segment depression
Inverted T waves=completed infarct

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14
Q

Nonischemic causes of ST segment elevation

Old EKGs are helpful to compare for new changes

A 
LVH
early repolarization
Ventricular aneurysm
LBBB
Veentricular paced rhythms
Pericarditis/myocarditis
Hypertrophic cardiomyopathy
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15
Q

Anterior wall EKG lines

A

V1-V4

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16
Q

Inferior wall EKG lines

A

II, III, and aVF

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17
Q

Lateral Wall EKG lines

A

I, aVL, V5 and V6

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18
Q

Posterior wall EKG lines

A

V1 & V2

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19
Q

ST segment depression

A

denote ischemia, possibly unstable angina

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20
Q

Q waves

A

develop after MI and denote transmural infarct

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21
Q

Inferted T waves

A

completed infarct, last EKG change to develop after MI

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22
Q

Inferior Wall MI

A 
Right coronary a. obstructed
may present with epigastric pain
HypoTN secondary to RV infarction-->tx with IVF bolus
Vagal stimulation causes bradycardia
No signs of CHF on CXR
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23
Q

Anterior Wall MI

A 
Left main or LAD a. obstructed
HypoTN and tachycardia due to LV failure
Requires beta agonist therapy
CXR will show CHF findings
higher mortality than inferior wall MI
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24
Q

AMI cardiac enzymes

A

Myoglobin
CPK-MB
Troponin

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25
Treatment for AMI
``` IV, O2 & monitor Aspirin Nitroglycerin SL or IV Morphine Beta-blockers Heparin ACE inhibitors ```
26
ED Discharge Criteria CP Patients
No ischemia on EKG No history of CAD Pain is atypical of acute coronary syndrome Initial cardiac troponin negative Age < 40 or 41<50 and repeat troponin at least 6 hours from symptom onset is negative
27
Antithrombin agents
Unfractionated IV heparin (UFH)--IV | Low molecular weight heparin (LMWH)--SQ
28
Antiplatelet Agents
Aspirin GPIIB/IIIA inhibitors--Abciximab-used if going for emergent angioplasty (PCI) Clopidogrel (Plavix) Ticlodipine (Ticlid)
29
How to treat bleeding complications for UFH/LMWH
protamine sulfate
30
Thrombolytics
``` t-PA Retavase TNK-tPA Max benefit if admin in first hr of CP Must have ST-segment elevation in 2 consecutive leads or new LBBB Risks--bad if CNS bleed ```
31
Percutaneous coronary intervention (PCI)
better long term outcomes than fibrinolytic therapy | Door-to-balloon time of 90 min.
32
Mechanical Complications of AMI
Free wall rupture: 1-5 days post MI | Papillary muscle rupture: new holosystolic murmur, mitral regurg and CHF, tx is surgical
33
Aortic dissection definition
intimal tear in lining of aorta. HTN is present 90%
34
History of AOrtic Dissection
Severe CP, max at onset Pain radiates to back &/or abdomen. MIGRATING PAIN TEARING SENSATION
35
Associated neurologic symptoms for aortic dissection
CVA, paraplegia, paresis, visual changes, can cause limb ischemia
36
PE of Aortic Dissection
Severe pain, HTN, absent/decreased peripheral pulses murmur in proximal dissections BP may be unequal in extremities
37
CXR of Aortic Dissection
Widening of mediastinum--caused by false lumen created by tear of aorta Follow abnormal CXR with CT chest or aortic angiogram
38
EKG findings in Aortic Dissection
LVH from long standing HTN | Ischemia of coronary a. dissected/occluded
39
Standford A classification of aortic dissection
involves ascending aorta only
40
treatment for stanford A classification
surgical correction needed
41
Stanford B classification of aortic dissection
only involves distal aorta
42
treatment for Stanford B classification
usually medical tx adequate | If complications, surgical correction
43
ED Treatment of aortic dissection
Pain control: Morphine drip BP management: Labetalol, Nitroprusside IV drip + Metoprolol Early surgical consultation for A and some B
44
Pulmonary Embolism History
pain pleuritic, lateral, and abrupt | Dyspnea & cough
45
RF for PE
``` period of immobilization casting after orthopedic procedure pregnancy or bc pills thrombophlebitis, heart disease, smokers FH or prior PE ```
46
PE for Pulmonary Embolism
``` tachypnea and tachycardia maybe thrombophlebitis maybe low grade fever rales and wheezes massive PE will present with shock syncope possible low pulse ox is a clue ```
47
Labs for PE
ABG will show pO2<80 | D-Dimer--HIGH sensitivity in PE and DVT
48
CXR for PE
atelectasis Hampton Hump--pulmonary infarction in lower lung Westmark's signs--decrease in blood flow in the are of the blood clot
49
EKG findings for PE
Nonspecific ST-T wave changes | Unexplained tachycardia!!
50
Gold standard for dx of PE but not widely available
Pulmonary angiogram
51
When to consider a doppler venous study to diagnose DVTs?
in pregnant patietns as first test
52
When is Ventilation-perfusion lung scan (V/Q scan) useful for PE?
if elevated serum creatinine>1.6
53
Current standard of care for diagnosing PE
Helical chest CT scan. IV contrast involved--need adequate renal fxn
54
Treatment for PE
Anticoagulation: IV heparin & start PO coumadin. (Lovenox injections if pregnant) Thrombolytics-for hemodynamically unstable pts Surgery/IR: pulmonary embolectomy, IVC filters
55
Hx for Pneumothorax
dyspnea>pain | CP is pleuritic and lateral
56
Possible Causes of PTX
chest trauma, spontaneous in tall thin males, iatrogenic
57
PE of PTX
Tachypnea and anxiety | decreased breath sounds
58
PE in tension PTX
tracheal deviation hypotension or altered mental status distended neck veins
59
CXR for PTX
absence of lung markings peripherally fine line shows pleural lining of lung EXPIRATORY FILMS INCREASE SIZE OF PTX ON CXR
60
Treatment for small PTX
conservative tx and resolves gradually
61
Tx for large PTX
tube thoracostomy. simple air aspiration is alternative
62
Tx for Tension PTX
immediate needle decompression at 2nd ICS/MCL followed by tube thoracostomy
63
Another name for Esophageal Rupture
Boerhaave's
64
Hx for Esophageal rupture
acute, severe CP following vomiting may have ass. abd pain/neck pain may have dyspnea, dysphagia, and hematemesis
65
PE for esophageal rupture
pneumomediastinum heard as HAMMAN'S CRUNCH subQ emphysemia may be palpable along chest wall/neck Tachypnea, tachycardia, and shock likely to develop
66
EKG for esophageal rupture
nonspecific changes
67
CXR for esophageal rupture
pneumomediastinum, subQ emphysema, an dpossibly L pleural effusion
68
Esophagram with gastrograffin for esophageal rupture
leaking of opaque media from the esophagus into the chest
69
Tx for esophageal rupture
``` rapid dx necessary--HIGH 48 HR MORTALITY Surgical repair ONLY option chest ube if effusion present Braod-spectrum ABX for mediastinitis FLuid resucscitation if shock present ```
70
Pericarditis pathogenesis
inflammation of the lining of the heart | effusion an develop-up to 50cc normal
71
Hx of Pericarditits
Pleuritic sharp CP relieved w/ leaning forward and aggravated by lying supine low grade fever dyspnea and dysphagia
72
PE for Pericarditis
Pericardial friction rub low grade fever JVD if large pericardial effusion (tamponade signs, beck's traid)
73
Beck's Triad
Hypotension, distended neck veins, muffled heart sounds
74
EKG for Pericarditits
Diffuse ST segment elevation PR segment depression T wave inversion maybe in later disease Will see CONCAVE St elevation. (vs. the tombstone ST elevation in an MI)
75
CXR in pericarditits
limited value unless large effusion
76
Echocardiography in Pericarditits
procedure of choice Fluid in pericardial space detected in front of RV RV collapse during diastole diagnostic of tamponade
77
Treatment of idiopathic or viral pericarditis
NSAIDS for 1-3 weeks outpatient
78
When to admit a pt with pericarditits?
If cardiomegally on CXR or if elevated cardiac enzymes
79
Tx for large pericardial effusion
peri-cardiocentesis

Emergency medicine (3 decks)

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