7 Deadly Chest Pain Flashcards
Somatic vs. Visceral pain
Somatic
- Easily described
- Precisely located
- Usually sharp
Visceral
- Difficult to describe
- Poorly localized
- Usually dull, heavy, or aching
Initial approach to chest pain
- ABCDE
- OMMILTVS
- EKG (<10 min interpretation)
- Hx
7 Deadly chest pains
- MI
- Aortic Dissection
- Cardiac Tamponade
- Esophageal Rupture
- Pneumonia
- Pulmonary Embolism
- Pneumothorax
Acute MI
- pathophys
Atherosclerotic plaque rupture → platelet thrombus formation → decreased coronary blood flow → ischemia → infarction
Acute MI
- RCA
Inferior Wall
Leads: II, III, AVF
Acute MI
- LAD
Anterior Wall
Leads: V1-V6
Acute MI
- Circuflex
Lateral Wall
Leads: I, AVL, V5, V6
Acute MI Risk factors
- Hyperlipidemia
- Diabetes
- Obesity
- Atherosclerosis
Acute MI
s/sx
- Chest pain
- Diaphoresis
- SOB
- Referred pain to neck/shoulder/arm
- +/- N/V
- +/- tachycardia
- +/- pallor
Acute MI
- Labs and Imaging
- CBC: H&H and platelets can help determine bleeding status
- CMP
- PT/INR
- Troponin
- EKG
- CXR
Acute MI
- Dx
- Chest pain or MI symptoms
EKG:
- 1 mm ST elevation in contiguous limb leads
- 2 mm ST elevation in contiguous precordial leads
- If ischemia present on EKG, look at opposite leads for infarct (ST elevation)
Acute MI
- Tx
- O2: Pulse ox < 94
- ASA
- Beta blocker
- +/- Nitro: Can use as long as systolic BP > 90
- Anticoagulation
- Glycoprotein IIb/IIIa inhibitors
- Reperfusion: PCI or thrombolytics
Aortic Dissection
- Pathophys
Violation of intima allows blood to dissect between intimal and adventitial layers of aorta
Aortic Dissection
- RF
- HTN
- Pregnancy
- MVA
- Connective tissue disorders: Marfan and Ehlers-Danlos **
Aortic Dissection
- S/Sx
- Tearing/ripping chest pain: Radiates to back
- Hypotension
- +/- neuro symptoms
Aortic Dissection
- Labs/imaging
- CBC
- PT/INR
- Blood type and crossmatching
- EKG
- CXR
Aortic Dissection
- Dx
- CXR, CT, or TEE (transesophageal echo)
- Widened mediastinum
Aortic Dissection
- Tx
- BP management: fluids, negative inotropic agent, vasodilator
- +/- surgical repair
Cardiac Tamponade
- Pathophys
- Increased fluid in pericardial sac causes restricted ventricular filling
- Intrapericardial pressures exceed normal filling pressures of R heart
Cardiac Tamponade
- RF
- Trauma
- SLE
- Malignancy
- Dialysis
Cardiac Tamponade
- S/Sx
Beck’s Triad
- JVD
- Hypotension
- Muffled heart sounds
Cardiac Tamponade
- Dx
- ECHO** (GS)
- EKG: Electrical alternans
- CXR: Water bottle heart
Cardiac Tamponade
- Tx
- Volume expansion
- Pericardiocentesis
Esophageal Rupture
- RF
- Alcoholism
- Frequent vomiting
- GERD
- Barrett’s esophagus
- Malignancy
Esophageal Rupture
- Causes
- Iatrogenic
- Boerhaave syndrome: transmural perforation associated with vomiting
- Trauma
- Foreign body
Esophageal Rupture
- s/sx
- Hamman crunch (auscultation sound)
- Subcutaneous emphysema
Esophageal Rupture
- Labs/imaging
PT/INR
Esophageal Rupture
- Dx
CT with water soluble contrast
Esophageal Rupture
- Tx
- Resuscitation
- Abx
- Sx repair
Pneumonia
- pathophys
Infection in the gas exchange portions of lungs
Pneumonia
- RF
age extremes
Pneumonia
- S/sx
- Chest pain
- SOB, Dyspnea
- Cough, sputum production
- Fever, chills, rigor
- Hypoxia
- Tachycardia, tachypnea
Pneumonia
- Dx
- Abnormal lung exam
- CXR with infiltrate**
Pneumonia
- Tx
- O2
- Blood/sputum cultures
- Abx: Vancomycin, Rocephin (ceftriaxone)
- Bronchodilators: albuterol, ipratropium
- Chest percussion therapy (CPT)
Pulmonary Embolism
- pathophys
- **Virchow’s Triad for Thrombosis Formation
1. Endothelial injury
2. Stasis of blood flow
3. Hypercoagulability - Proximal portion of venous clot dislodged
- Travels through veins to R ventricle
- Becomes lodged in pulmonary arteries
Pulmonary Embolism
- RF
- Recent surgery
- Recent trauma w/ fracture
- Recent hospitalization
- Prolonged sedentary state
- Birth control
- Hx of DVT
- Hypercoagulable state: Pregnancy, Factor V Liden, Protein S
Pulmonary Embolism
- S/sx
- SOB
- chest pain
- dyspnea
Pulmonary Embolism
- Dx
- CT Angiography** (GS)
- D-dimer (screening)
- Ventilation perfusion scan
Pulmonary Embolism
- Tx
- Anticoagulation
- Thrombolytics
- Clot retrieval
Pneumothorax
- pathophys
Air enters potential space between parietal and visceral pleura
Pneumothorax
- RF
- Trauma: MVA MC cause
- Tall, thin frame
- Smoker
- Young
Pneumothorax
- S/sx
- Chest pain
- SOB
- Dyspnea
- Subcutaneous emphysema
- Displaced trachea/mediastinum
Pneumothorax
- Dx
CXR: except tension pneumonia
Pneumothorax
- Tx
- O2
- Needle decompression
- Thoracostomy tube
- Cardiovascular surgery: Definitive treatment for prevention of recurrence
