The Evaluation of Chest Pain in the Emergency Setting - Brown Flashcards Preview

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Flashcards in The Evaluation of Chest Pain in the Emergency Setting - Brown Deck (55):
1

Pathogenesis of Chest Wall Pain

  • irritation
  • trauma
  • compression of structures
  • muscles
  • cartilaginous structures
  • nerves
  • bones

2

Gastroesophageal Reflux

 

Describe the presentation and characteristics of gastrointestinal causes of chest pain 

  • substernal burning and pain
  • starts in epigastrium and radiates upward
  • related to consuming large meal, lying down, or bending over
  • relieved by antacid or food

2

Treatment Algorithm: strongly suspicious for injury

start adjunctive treatments

  • B-adrenergic receptor blockers
  • nitroglycerine
  • heparin
  • ACE inhibitors

time from onset of symptoms

  • < 12 hours - select a reperfusion strategy
    • angiography
    • PCI
    • CT surgery
    • fibrinolytic therapy
  • > 12 hours - not candidate for fibrinolytics
    • treat as non-ST elevated AMI (cath, revascularization)

3

Chest Pain - Musculoskeletal or Nerve Origin

 

Describe the presentation and characteristics of chest pain that is musculoskeletal or nerve origin

  • lasts few seconds to days, months, maybe longer
  • sharp, dull or aching
  • aggravated by deep breathing or cough
  • point-tenderness on palpation
  • may be dermatomal
  • occurs with movement
  • bone pain is well localized

3

Costochondritis

 

Describe the presentation and characteristics of chest pain that is musculoskeletal or nerve origin  

  • sharp, well localized pain
  • most intesne at costochondral junction
  • palpation reproduces pain
  • warmth, erythema and swelling
  • aggravated by deep breathing and cough

3

Pulmonary Embolism

 

Describe the presentation and characteristics of pulomonary causes of chest pain 

 

Risk Factors:

  • immobility
  • recent surgery
  • pregnancy or oral contraceptive use
  • large bone fracture
  • malignancy
  • DVT or prior PE
  • CHF
  • COPD
  • obesity
  • hypercoagulability

Presentation:

  • pleuritic chest pain
  • sudden onset dyspnea
  • tachypnea and tachycardia
  • hypotension
  • hemoptysis possible

Examination:

  • rales (crackles) and pleural friction rub

4

Absolute Contraindications to Fibrinolytic Therapy

 

List the indications and contraindications for thrombolytic therapy

  • history of intracranial hemorrhage
  • known intracranial neoplasm or vascular lesions
  • active bleeding or known bleeding disorder
  • embolic stroke within 3 months
  • suspected aortic dissection
  • significant facial or head trauma within 3 months

5

Options for testing of CAD

  • treadmill - exercise tolerance test (ETT)
  • stress myocardial perfusion imaging
  • stress echo

6

NSTEMI

 

Describe the classification of Acute Coronary Syndrome and the inital evaluation based upon 12-lead ECG findings

  • occluding thrombus sufficient to cuase tissue damage and mild myocardial necrosis
  • ECG:
    • can look normal
    • ST depression +/- T wave inversion
  • Elevated cardiac enzymes

8

non-invasive testing for chest pain

 

Describe common non-invasive tests used to evaluate chest pain.

  • Electrocardiogram
  • Exercise Treadmill Testing
  • Stress Myocardial Perfusion Imaging
    • Nuclear stress testing
    • Pharmacologic stress
      • adenosine, dipyridamole, dobutamine
      • sestamibi
  • Stress Echocardiography

9

History and Physical Exam of patients with Chest Pain

 

 Describe the diagnostic evaluation of patients with chest pain including H & P, diagnostic tests, initial management and patient education

History

  • if emergent brief targeted history, get more details later
  • OLD CHARTS

Physical Exam

  • asses level of stress and anxiety
  • BP in both arms (doppler if needed)
  • postural BP
  • skin
    • pallor, cyanosis
    • jaundice
    • herpes zoster rash
  • eyes - fundoscopic exam
  • neck
    • lymphadenopathy
    • thyromegaly
    • tracheal shift
    • JVD
    • carotid bruits
  • chest wall
    • signs of trauma
    • heaves or lifts
    • palpate for tenderness
  • complete heart exam
    • extra heart sounds
    • murmurs, clicks, hums, rubs
    • irregularities
    • arrhythmias
  • lungs
    • equal breath sounds, plerual rub
    • crackles
    • ronchi
    • wheezes
  • Abdomen
    • bowel sounds and bruits
    • tenderness, masses
    • organomegaly
    • ascitis
  • Lower Extremities
    • femoral and peripheral pulses
    • cyanosis
  • Musculoskeletal and Neurological
    • patients with pain on motion
    • focus on focal tenderness
    • motor or sensory deficits

10

Cardiopulmonary or Vascular Differential Diagnosis of Chest Pain

 

Give a broad differential diagnosis of chest pain listed by organ system.

  • MI
  • Aortic Dissection
  • Pericarditis
  • Pulmonary Embolism
  • Valvular Disease
    • Aortic Stenosis
    • Mitral Valve Prolapse
  • Bacterial Endocarditis
  • Hypertrophic Obstructive Cardiomyopathy
  • Myocarditis

11

Classification of Acute Coronary Syndromes

 

Describe the classification of Acute Coronary Syndrome and the inital evaluation based upon 12-lead ECG findings

  • Unstable angina pectoris
  • non-ST segment elevation MI (NSTEMI)
  • ST segment elevation (STEMI)

13

Pleural Causes of Chest Pain

 

Describe the presentation and characteristics of chest pain that is pleural in origin

  • worsened by deep inspiration or coughing
  • spasm secondary to:
    • cold weather
    • increased activity

13

gastrointestinal causes of chest pain 

 

 

give a broad differential diagnosis for chest pain listed by organ system

  • Gastroesophageal reflux
  • Esophageal spasm
  • Cholecystitis
  • Peptic ulcer disease
  • Pancreatitis

 

GI Disorders are associated with eating, relief with antacids.

14

Fibrinolysis Indications

 

List the indications and contraindications for thrombolytic therapy

  • ST segment elevation > 1 mm in two contagious leads
  • new LBBB
  • symptoms consistent with ischemia
  • symptom onset less than 12 hours prior to presentation

15

Unstable Angina

 

Describe the classification of Acute Coronary Syndrome and the inital evaluation based upon 12-lead ECG findings

  • non-occlusive thrombus
  • ECG: non-specific ECG; ECG can look normal
  • normal cardiac enzymes

16

Nerve Root Compression

 

Describe the presentation and characteristics of chest pain that is musculoskeletal or nerve origin

  • results in pain and motor/sensory deficits
  • numbness or tingling in neck, chest, upper arm

17

AMI Symptoms in African Americans

  • abdominal pain
  • absence of chest pain
  • dizziness/weakness
  • fatigue
  • hot and flused
  • indigestion
  • palpitations

18

AMI Symptoms in the Elderly

  • absence of chest pain
  • diaphoresis
  • dyspnea
  • faintness
  • syncope
  • nausea
  • vomiting

19

Diagnostic Testing in patients with Chest Pain

 

Describe the diagnostic evaluation of patients with chest pain including H & P, diagnostic tests, initial management and patient education

based on the data from the H &P

  • pulse oximetry
  • cardiac enzymes
  • CBC and complete metabolic panel
  • 12 lead ECG
  • chest x ray
  • others to consider
    • echocardiogram
      • mitral valve prolapse
      • valvular disorders
    • aortic aneurysm or dissection
      • CT with contrast
      • TE echo
      • aortic angiography
    • cardiac catheterization
    • stress echo
    • spiral CT
      • pulmonary embolism

 

20

"Atypical" Chest Pain

  • doesn't fit a common pattern
  • no abnormal exam or diagnostic findings
  • usually self-limited and resolves on own
  • diagnosis of exclusion

21

AMI Symptoms in Women

  • absence of chest pain
  • nausea
  • vomiting
  • hypotension with tachycardia
  • right arm, neck, jaw pain
  • back pain
  • dyspnea
  • headache

22

Treatment Algorithm: suspicious for ischemia

  • NOT candidates for fibrinolytic therapy
  • Adjunctive treatment
    • heparin
    • aspirin
    • glycoprotein receptor inhibitors
    • nitroglycerin
    • B-adrenergic receptor blockers
  • Assess clinical status
    • ischemia
    • depressed LB function
  • condiser cardiac cath and revascularization

22

Pathogenesis of gastrointestinal problem chest pain

Structural Defects

  • lumen laxity
  • obstruction
  • distension

Mucosal or organ irritation, inflammation or infection

  • esophagus
  • abdominal organs

23

Describe the presentation and characteristics of psychiatric or mental disorder causes of chest pain 

  • Psychogenic Chest Pain
    • generalized, constant
    • aggravated by any effort
    • present in times of stress, absent at non-stress time
  • Associated Symptoms
    • Dyspnea
    • Fatigue
    • Headache
    • Hyperventilation
    • somatic symptoms

25

Spontaneous Pneumothorax

 

Describe the presentation and characteristics of pleural causes of chest pain 

  • secondary to trauma or disease
  • more common in: young men, smokers, COPD
  • pain pattern
    • acute unilateral, stabbing pain
    • dyspnea
  • examination
    • decreased breath and voice sounds

** beware of mediastinal shift and Tension Pneumothorax

A image thumb
26

Myocardial Infarction

 

Describe the characterisitics of chest pain due to various cardiac conditions

  • chest pain
  • other symptoms
    • dyspnea
    • diaphoresis
    • anxiety
    • palpitations
    • nausea
    • vomiting
  • lasts 20-30 minutes or longer
  • unrelieved or only partial relief with nitro or  MS

27

Mitral Valve Prolapse

 

Describe the characterisitics of chest pain due to various cardiac conditions

  • patients are asymptomatic; symptoms may occur (15%)
    • chest pain - sharp, not relieved by nitro, unrelated to exertion
    • fatigue
    • shortness of breath
    • palpitations when lying on left side
    • lightheadedness
    • dizziness
    • hedache
    • mood swings
  • auscultatory feature:
    • midsystolic click or multiple clicks
    • midsystolic to late systolic murmur at the apex of left ventricl over teh mital area

28

Chest Pain due to Cardiac Disease

 

  • mild to severe
  • transient, exertional pain
  • often radiates to jaw or arms
  • may be associated with
    • weakness
    • dyspnea
    • diaphoresis
    • nausea
    • vomiting
    • palpitations
    • anxiety

29

Plan and Management in patients with Chest Pain

 

 

Describe the diagnostic evaluation of patients with chest pain including H & P, diagnostic tests, initial management and patient education

 

Pain relief - nitro or MS - relieve to a 0 of 10

Ischemic Heart Disease/Acute Coronary Syndrome

  • thrombolytic therapy
  • cardiac cath

Other cardiac or pulmonary problems

  • treatment based upon establishing diagnosis

Psychogenic Problems

  • reassurance
  • appropriate referral

 

29

Factors that Increase Risk of AMI

  • hypotension
  • tachycardia
  • pulmonary crackles
  • JVD
  • pulmonary edema
  • new murmurs
  • heart sounds
  • diminished peripheral pulses
  • signs of stroke

30

Diagnosis of STEMI/NSTEMI

2 of the following

  • ischemic symptoms
  • diagnostic ECG changes
  • serum cardiac marker elevation
  • wall motion abnormalitiy on echo

31

AMI Symptoms with Comorbidities

(Diabetes, Heart Failure)

  • Diabetes
    • silent MI
  • Heart failure
    • less likely to have CP
    • may have atypical symptoms

32

Cardiac Care Goals

  • decrease amount of myocardial necrosis
  • preserve LV function
  • prevent major adverse cardiac events
  • treat life threatening complications

34

Dissecting Aortic Aneurysm

 

Describe the characterisitics of chest pain due to various cardiac conditions

pain:

  • excruciating, tearing, knifelike pain; sudden onset, lasts hours
  • anterior chest
    • may be abdomen or back pain
    • often radiates to thoracic back

risk factors:

  • hypertension
  • connective tissue disease
  • pregnancy
  • arteriosclerosis
  • cigarette smoking

common signs:

  • lowered or elevated BP - widened pulse pressure
  • dissociation of arm BP
  • absent pulses
  • paralysis
  • pulsus paradoxus
  • aortic insufficiency murmur

35

Mechanical and Revascularization Therapy for Ischemic Heart Disease

  • Coronary Angioplasty
    • Percutaneous Interventions - balloon angioplasty, stent placement
  • CABG - Coronary Artery Bypass Grafting
  • Enhanced External Counterpulsation

36

Cocaine-Induced Chest Pain

 

Describe the presentation and characterisitcs of chest pain that is non-cardiac.

  • severe, sharp, pressure-like or squeezing substernal pain
  • associated symptoms
    • euphoria
    • mydriasis
    • hyperstimulation
    • paranoia
    • delusions
    • nausea
    • muscle twitching
    • depression
  • complications
    • myocardial ischemia and infarction
    • arrythmias
    • respiratory failure
    • circulatory collapse

38

Panic Disorder

 

Describe the presentation and characteristics of psychiatric or mental disorder causes of chest pain 

 

chest pain with intesne fear

  • tachypnea
  • palpitations
  • diaphoresis
  • trembling
  • nausea
  • dizziness
  • syncope or near syncope
  • chills or hot flashes

39

STEMI Cardiac Care

Assessment

  • Time since onset: 90 minutes for PCI/ 12 hours for fibrinolysis
  • Determine if fibrinolysis candidate
    • < 3 hours from onset
    • PCI unavailable or delay
    • if no contraindications
    • door to needle goal < 30 minutes
  • Determine if PCI candidate
    • if available
    • door to ballon < 90 minutes
    • if fibrinolysis is contraindicated
    • late presentation > 3 hours
    • STEMI is in doubt

40

Education for patients with Chest Pain

 

Describe the diagnostic evaluation of patients with chest pain including H & P, diagnostic tests, initial management and patient education

  • cardiology consult if indicated
  • cardiovascular risk reduction
  • recognition of cardiac chest pain - seek medical attention 911
  • proper use of medication
    • nitro for angina
    • other prescribed meds

41

Pericarditis

 

Describe the characterisitics of chest pain due to various cardiac conditions

  • Paroxysmal pain
  • Pain decreased with sitting and leaning forward
  • Friction Rub
  • May be associated with:
    • fever
    • tachycardia
    • pulus paradoxus
    • cardiac tamponade
    • elevated ESR and leukocytosis
  • Risk factors: infection, autoimmune disease, recent MI, cardiac surgery, malignancy uremia

42

Pathogenesis of lungs and adjacent structures chest pain

  • irritation/inflammation of lung tissue, pleura, diaphragm
  • infection
  • chronic disease
  • neoplasm
  • reactive airway/bronchospasm

43

Relative Contraindications to Fibrinolytic Therapy

 

List the indications and contraindications for thrombolytic therapy

  • uncontrolled severe hypertension
  • prolonged cardiopulmonary resuscitation or recent surgery or noncompressive vascular puncture
  • current anticoagulation 
  • streptokinase
    • prior exposure to the drug
    • hx of allergic reaction

44

Pathogenesis of Cardiac Chest Pain

  • low-flow states of myocardium (CAD)
  • spasm
  • tissue hypoxia
  • anaerobic metabolism
  • lactic acidosis

 

46

Angina Pectoris

 

Describe the characterisitics of chest pain due to various cardiac conditions

  • Usually lasts less than 10 minutes
  • Relieved by rest or with nitroglycerine

47

Pleural Effusion

 

 

Describe the presentation and characteristics of chest pain that is pleural in origin

  • Transudates
    • congestive heart failure
    • acute atelectasis
    • pulmonary embolism
  • Exudates
    • pneumonia
    • cancer

A image thumb
48

Bacterial Pneumonia

 

Describe the presentation and characteristics of chest pain that is pleural in origin

  • most common cause of pleuritic pain
  • fever
  • chills
  • cough
  • leukocytosis
  • localized physical exam - chest x-ray findings

49

Emergency Department approach to a patient presenting with chest pain

initial assessment and life-saving treatment of chest pain patients in the ED

 

RULE OUT greatest life threat first

Treat to prevent potential complications

Intitial Assessment

  • measure vital signs
  • measure oxygen saturation
  • obtain IV access
  • administer O2
  • monitor

Brief, targeted H&P

  • eligibility for fibrinolytic therapy

Initial Diagnositc Studies

  • 12-lead ECG
  • serum cardiac marker levels
  • electrolytes and coagulation studies
  • portable CXR

Targeted Phsyical

  • vitals
  • cardiovascular system
  • respiratory system
  • abdomen
  • neurological status

Emergent Care

  • aspirin
  • nitrates

50

AMI Symptoms in Hispanics

  • abdominal pain
  • chest pain
  • cough
  • cramping or burning chest pain
  • palpitations
  • upper back pain

51

Treatment Algorithm: NOT unstable angina and troponin is negative

  • if further evidence of ischemia or infarction
    • persistent symptoms
    • depressed LV function
  • consider cardiac catheterization
  • anatomy suitable for revascularization: PCI, CABG

52

Pharmacologic Management - Therapy for Ischemic Heart Disease

 

List common classes of drugs used to treat chest pain in the emergency setting

  • Nitrate Therapy
    • Sublingual PRN
    • Chronic therapy: oral/transdermal
    • Emergency: IV
  • B-Blockers
  • Ca Channel Blockers
  • Antiplatelet Agents
    • Aspirin
    • Clopidrogrel (Plavix)

53

STEMI

 

Describe the classification of Acute Coronary Syndrome and the inital evaluation based upon 12-lead ECG findings

  • complete thrombus occlusion
  • ECG:
    • ST elevations on ECG or new LBBB
  • cardiac enzymes: elevated

54

Pathogenesis of psychogenic disorder chest pain

  • secondary to anxiety, depression, other psych disorder
  • illicit drug use

55

Esophageal Spasm

 

Describe the presentation and characteristics of gastrointestinal causes of chest pain 

  • intesne, substernal, sharp pain
  • may radiate to interscapular region
  • may be relieved by nitroglycerine