Chest Pain - Exam 1 Flashcards by Johannah Crumpton

What are the two different types of chest pain? What will each feel like? Will it radiate?

visceral: Discomfort, heaviness, pressure, tightness, aching are commonly used descriptors

pain WILL RADIATE

Somatic: Sharp, stabbing, scratchy, without radiation

does not radiate and usually only in 1 area

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What organs does visceral type pain usually involve? somatic pain?

heart, blood vessels, esophagus, and visceral pleura

innervates the chest wall, from the dermis to the parietal pleura

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What type of pain is difficult to describe and localize? Which one is easily described and precisely located?

visceral: difficult to describe and localize

somatic: easily described and precisely located

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What are the 5 chest pain red flags?

Abnormal vital signs
concerning EKG findings
hx of prior CAD
multiple ASCVD risk factors
Abrupt onset, new or severe chest pain or dyspnea

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What vital signs are considered unstable?

RR >24
HR less than 60 or greater than 120
Abnormal BP
O2 less than 90%

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What is the initial management for a pt complaining of chest pain?

Placed in a treatment bed quickly

Cardiac monitoring and IV access (2 large bore)

EKG (within 10 minutes)

Measure vital signs, then resuscitate as needed, following the ABCs

Administer supplemental oxygen if O2 saturation at rest is < 95%*

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What are the top 6 ddx that can kill you the fastest with a chest pain CC?

ACS

Aortic dissection

Severe PNA

Tension Pneumothorax

Esophageal rupture

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If the pt is complaining of pleuritic chest pain, what are the 3 top ddx you should be thinking?

Pulmonary embolism

Pneumonia

Spontaneous pneumothorax

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WShat am I?

Acute coronary syndrome

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What am I?

pulmonary embolism

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Aortic dissection

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Pneuomnia

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Esophageal rupture

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Pneumothorax

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pericarditis

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perforated peptic ulcer

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What is the associated timeframe that an EKG needs to be completed by? Does a normal EKG rule out an ACS event?

EKG within 10 minutes upon presentation to the ED

normal EKG does NOT rule out ACS event

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EKG is normal, now what should you do?

repeat in 15-30 minutes if initially normal, consider serial EKGs

compare to previous EKGs

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______ is the first line cardiac enzyme used in the ED. When does it elevate?

troponin

4 hours after onset of acute MI

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When do troponin levels peak? **What do you need to remember about troponin levels?

Peaks in 24-48 hours, remains elevated or multiple days

If patient has multiple infarctions in a short amount of time, will remain elevated and is NOT a reliable detector of re-infarcts

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_____ is used only if troponin isn’t available or if patient has had an MI in the last 2-3 days. When does the level start to normalize?

CK-MB

levels normalize in 48-72 hours

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_____ and _____ should be ordered if concerned about PNA or pneumothorax?

CXR

non-contrast CT

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______ should be ordered if concerned about aortic aneurysm/dissection or PE

Chest CTA

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______ is used to dx aortic dissection, cardiac tamponade, new regurgitant murmur

Echocardiography

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_______ can also present as ishemia/chest pain so important to check CBC

severe anemia

What 4 findings would necessitate an hospital admit if found in combo with chest pain?

Positive cardiac enzymes New concerning EKG changes Persistent pain Concerning physical exam findings

If the pt does NOT have ____, ____ and ______ it is UNLIKELY to have ACS

Negative EKG, cardiac enzymes, and chest x-ray = unlikely to have ACS

**What does a HEART score of 0-3 mean?

2.5% chance of Major adverse cardiac event in next 6 weeks Discharge home

**What does a HEART score of 4-6 mean?

20.3% chance of MACE event admit for clinical observation

**What does a HEART score of 7-10 mean?

72.7% MACE need early invasive strategies

What is defined as a hypertensive crisis? How does this measurement need to be defined?

Defined as a SBP >180 mm Hg and/or DBP >120 mm Hg BP should be assessed in both arms multiple times

What are the two types of hypertensive crisis? What are the differences?

Hypertensive urgency - no evidence of end-organ damage Hypertensive emergency - evidence of end-organ damage

What organs are effected the most in a hypertensive crisis?

brain, heart, aorta, kidneys, eyes

What are some fundoscopic findings that would indicate end organ damage?

flame hemorrhage, optic disc swelling,

What are some H&P findings that would indicate end organ damage?

Mental status changes, neurologic dysfunction, seizure, acute severe HA Visual changes, retinopathy, papilledema Sudden onset chest pain Dyspnea Peripheral edema Oliguria

What is the management for hypertensive urgency? What is the drug of choice? When do they need to follow up with PCP?

need to control BP within 24-48 hours No hx of HTN: HCTZ Hx of HTN: reinstitution or intensification of oral antihypertensive therapy PCP follow up within 48 hours

How much do you need to reduce BP by in the first hour in a hypertensive crisis? If stable, then what do you do

reduce SBP by no more than 25% in the 1st hour reduce to 160/100 mm Hg over the next 2 to 6 hours

What happens in a hypertensive crisis if the BP is reduced TOO FAST?

watershed cerebral infarction aka most distal areas do not get blood supply due to sudden drop in BP

What is the ideal BP for an aortic dissection?

Aortic dissections which require rapid reduction to SBP between 100-120 with in 20 minutes

Acute ischemic stroke with CI to tPA BP are not lowered unless is it _____

≥ 185/110

What is the goal BP for Intracerebral hemorrhage?

SBP gole is 130-140 mmHg

**What is the preferred BP agent for BP crisis in pregnancy?

Hydralazine

** What are the 2 preferred BP lowering agents in strokes?

Enalaprilat or Labetalol

**______ is the preferred BP lowering agent in the ED for renal insufficiency?

Fenoldopam

______ is the preferred BP lowering agents in the ED for aortic dissections?

Esmolol

______ is the preferred BP lowering agents in the ED for SAH and ischemic strokes

nicardipine

_____________ is the preferred BP lowering agents in the ED for CHF?

enalaprilat

What is another name for esophageal rupture? Where is it most likely to tear?

Boerhaave Syndrome distal ⅓ of the esophagus

What is the MC etiology of an esophageal rupture? Almost all (90%) occur along the _______ of the distal esophagus

forceful vomiting/coughing - MC left posterolateral wall

How will esophageal rupture present? Where does it radiate? What makes it worse?

Sudden onset substernal chest pain following an episode of forceful vomiting to the neck or abdomen neck flexion, breathing, and swallowing

What is Hamman's crunch? What condition is it associated with?

audible crepitus that varies with the heartbeat on auscultation of the precordium, is a rare finding associated with pneumomediastinum esophageal rupture

When will a CXR be normal in an esophageal rupture? What other imaging is used to dx?

CXR will be normal within the first 1-2 hours Contrast esophagram or CT with IV contrast chest

pleural effusion caused by esophageal rupture is mc left or right?

LEFT is more common than right

What are the arrows pointing to?

pneumomediastinum a condition where air leaks into the mediastinum, the space in the chest between the lungs

What is the management for esophageal rupture?

What is cardiac tamponade? What side of the heart?

An accumulation of fluid within the pericardial space that affects the normal filling pressures of the RIGHT heart chambers.

Why is cardiac tamponade an emergency?

due to severe diastolic dysfunction that leads to reduced cardiac ouput, which leads to cardiogenic shock and then death

Development of diastolic dysfunction in cardiac tamponade results in relation to what 3 things?

rate of fluid accumulation pericardial compliance intravascular volume (hypovolemia lowers ventricular filling pressure)

What are 7 causes of atraumatic cardiac tamponade?

**What is Beck's triad of cardiac tamponade?

hypotension (with narrow pulse pressure) jugular venous distention distant heart sounds

How will cardiac tamponade present?

dyspnea at rest and exertion tachycardia hypotension with narrow pulse pressure pulsus paradoxus JVD distant heart sounds

What is pulsus paradoxus? Where is it palpable?

A drop of SBP by > 10-20 mmHg during inspiration Often palpable in the radial, brachial, or femoral pulses as a weakening or disappearance of the pulse during inspiration

_____ is the most sensitive and specific dx tool for cardiac tamponade?

TTE

What will the EKG show on a pt with cardiac tamponade?

low voltage QRS electrical alternans signs of underlying dz (pericarditis?

What will pericarditis present like on EKG?

diffuse ST segment elevation

What will the CXR show of a pt with cardiac tamponade?

may be normal or show an enlarged cardiac silhouette

What is the management of cardiac tamponade?

Chest Pain - Exam 1 Flashcards

(68 cards)