Acute chest pain and SOB Flashcards
Ddx for chest pain?
- MSK
- ACS
- Pneumothorax
- Oesophagitis
- Pneumonia
- PE
- Aortic dissection
- Myocarditis/ pericarditis
- Pancreatitis
- Vertebral collapse
How to take a chest pain history?
- Site
- Onset
- Character
- Radiation
- Associated symptoms e.g. breathless, N&V, sweating, haemoptysis, palps, dizziness, LOC
- Relieving factors and precipitating factors
- TIming- what were you doing when it came on, has it worsened, got better or stayed the same, is it intermittent or constant
- Severity- out of 10
What encompasses ACS?
- Unstable angina
- NSTEMI
- STEMI
Risk factors fo MI?
- smoking
- HTN
- age
- male
- diabetes
- Hyperlipidaemia
- fhx
Pathophysiology of MI?
- Usually affects L. ventricle
- Sudden occlusion of a coronary artery or one of its branches by thrombosis over a pre-existing atheromatous plaques
- People with IHD are at risk of having an MI if there is additonal stress places onto their critically impaired myocardial circulation e
- MI may also occur in vasculitic processes e.g. cranial arteritis and kawasaki disease
Diagnosis of acute MI?
i.e. what features are needed for dx of acute MI
2 out of 3 of the following features:
* history of cadiac type ishcaemia chest pain
* Evolutionary changes on serial ECGs
* a rise in serum cardiac markers
Classic presentation of MI?
- sudden onset, severe, constant central chest pain which radiates to the arms, neck, or jaw
- More severe than angina
- unrelieved by GTN
- Pain usually accompanied by one or more: sweating, nausea, vomiting and breathlessness
Atypical presentation of MI?
- symptoms similar to indigestion e.g. new dyspeptic pain
- Up to a 1/3 of pts with acute MI do not report any chest pain
- LVF
- collapse or syncope
- confusion
- stroke
- incidental ECG finding
Need to enquire about IHD, contraindications about drug history, incl drugs of abuse e.g. cocaine
Who tends to have atypical presentations of MIs
- older
- more likely to be female
- hx of diabetes or HF
Examination and initial resuscitation in ?acute MI (think of ddx as well)
- Maintain SpO2 in the normal range, IV cannula, analgesia
- Appearance: pt may be pale, sweaty and distressed
- Exam may be normal, unless they have complications
- Pulse, BP and monitor trace (? arrythmia or cardiogenic shock)
- Listen to the heart (murmurs or 3rd heart sound)
- Listen to lungs (?LVF, pneumonia, pneumothorax)
- Check peripheral pulses (?aortic dissection)
- Check legs (DVT/ PE)
- Palpate for abdo tenderness or masses ( ? cholecystitis, pancreatitis, perforated peptic ulcer, ruptures aortic aneurysm)
Investigations in MI?
- ECG within mins of arrival at hospital, if ECG is normal but there are suspicious symptoms, repeat the ECG after 15 mins and re-evaluate
- Review old notes (and previous ECGs for comparions)
- Monitor BP and RR
- Obtain venous access and send blood for cardiac markers, U&Es, glucose, FBC and lipids
- Obtain CXR if there is suspicion of LVF or aortic dissection
Other causes of high troponins?
- pericarditis
- PE with large clot burden
- sepsis
- Renal impairment reduces the excretion of troponin so can result in higher levels
STEMI treatment?
- Give O2 if needed and attach cardiac monitor
- Contact cardiology for PCI
- Provide IV morphine +/- antiemetic
- Ensure pt has had aspirin 300mg (usually prehospital)
- IV access and take samples for U&Es, glucose, FBC and troponin
- Give 2nd antiplatelets agent as per local protocol (e.g. ticagrelor loading dose 180mg PO, or prasugrel or clopidogrel)
- Arrange immediate transfer to cath lab for PCI < 12hr from symptoms onset (or > 12 hrs with cardiogenic shock)
- If PCI cannot be delivered within 90 mins, assess the rick of bleeding and offer thrombolysis
- If pain continues, give IVI GTN ( 0.6mg/hr and increase as necessary), provided systolic BP is >90 mmHg
- Consider atenolol (5mg IV slowly over 5 min, repeated once after 15 min), unless contraindicated (e.g. uncontrolled HF, hypotension, bradyarrhythmias, COPD)
Contraindications for ticagrelor?
- hx of intracranial haemorrhage
- Has active bleeding
- moderate hepatic impairment
- on an anticoagulant
Indications for PCI or thrombolysis?
- ST elevation of > 1 mm in 2 limb leads, or
- ST elevation of >2mm in 2 or more contiguous chest leads or
- LBBB in the presence of a typical hx of acute MI
does NOT have to be new LBBB
When can you perform PCI?
- within 90 mins of diagnosis and within 12 hours of symptom onset
- If this cannot be done- thrombolysis
Features of unstable angina?
- angina at rest
- increased frequency of angina
- increased duration of angina
- increased severity of pain
Hard to distinguish between unstable angina and NSTEMI
Initial management of unstable angina/ NSTEMI
- Provide O2 if SpO2 if <90%
- attach cardiac monitor
- Administer IV opioid analgesia (+/- antiemetic) as required
- Give aspirin 300mg orally (PO), if not already adminstered
- Give clopidogrel 300mg PO according to local guidelines
- Start fondaparinux 2.5mg SC daily, unless there is contraindication
- if pain is unrelieved start GTN IVI (0.6mg/hr and increase as necessary, provided systolic is > 90mmHg)
- Discuss all pts with a NSTEMI, TIMI >3 or GRACE > 100 with cardiology team- they may benefit from early revascularization procedure
- High TIMI/ GRACE and low bleeding risk consider glycoprotein IIb/IIIa inhibitors (eg eptifibatide and tirofiban) with IV heparin.
- if high risk of NSTEMI, haemodynamically stable, and no contraindications consider atenolol ( 5mg IV slowly over 5min, repeated once after 15min)
- Maintin blood glucose < 11mmol/L
- Refer for admission, repeat ECGs and troponins
When would you NOT give fondaparinux in NSTEMI/ unstable angina?
- high risk of bleeding
- renal impairment
- plan to go to cath lab (give IV unfractionated heparin instead)
Atenolol contraindications?
- hypotension
- bradycardia
- second or third degree heart block
- heart failure
- severe reactive airway diseases
What is aortic dissection?
tear in tunica intima of the wall of the aorta
associations of aoritc dissection?
- hypertension (most imp RF)
- trauma
- bicuspid aortic valve
- collagens: Marfans, Ehlers Danlos
- Turners and noonans syndrome
- pregnancy
- syphilis
Features of aortic dissection?
- chest/ back pain: typically severe and sharp- ‘tearing’ in nature
- Pain is typically maximal at onset
- pulse deficit- weak or absent carotid, brachial or femoral pulse
- variation > 20 mmHg in systolic BP between the arms
- aortic regurg
- hypertension
- symptoms correspond to arteries involved e.g. coronary arteries–> angina, spinal arterie –> paraplegia, distal aorta –> limb ischaemia
Classification of Aortic dissection?
- Stanford classification
- type A: ascending aorta 2/3 of cases
- type B- descending aorta, distal to left subclavian, 1/3 of cases
Inv in aortic dissection?
- Cxr: widened mediastinum
- CT angiography of CAP- inv of choice: suitable for stable pts and planning surgery. FALSE lumen is the key finding
- Transoesophageal echocardiography (TOE) more suitable for unstable pts who you cannot take into CT scanner
Management of Aortic dissection?
Type A:
* surgical management, but BP should be controlled to target systolic of 100-120 mmHg whilst waiting intervention
Type B:
* conservative management
* bed rest
* reduce blood pressure IV labetalol
Complications of aortic dissection?
Backward tear:
* aortic incompetence/ regurg
* MI- inferior pattern is often seen due to right coronary involvement
Forward tear:
* unequal arms pulses and BP
* stroke
* renal failure
What is pericarditis?
- Inflammation of the pericardial sac, lasting for less than 4-6 weeks
Causes of pericarditis?
- Viral infections (Coxsackie)
- TB
- Uraemia
- Post- MI
- Radiotherapy
- Connective tissue disease e.g. SLE and RA
- Hypothyroidism
- Malignancy e.g. breast and lung
- Trauma
What pericarditis do you get early after an MI?
1-3 days
fibrinous pericarditis
What is Dressler’s syndrome?
Autoimmune pericarditis
Week-months post MI
Features of pericarditis?
- Chest pain- may be pleuritc, relieved by sitting forward
- Non- productive cough
- Dyspnoea
- Flu-like symptoms
- Pericardial rub
ECG changes in pericarditis?
- widespread saddle shaped ST elevation
- PR depression (most specific ECG marker for pericarditis)
Inv for pericarditis?
- ECG
- Transthoracic echo in all pts with transthoracic echo
- Bloods- inflammatory markers
- Some pts may have elevated troponis- this indicates possible myopericarditis
Management of pericarditis?
- mostly managed as outpatients
- High risk features e.g. fever >38 or elevated trops- managed as inpatient
- Treat any underlying cause
- Strenuous physical activity should be avoided until symptom resolution and normalisation of inflammatory markers
- NSAIDs and colchine is now used 1st line for acute idiopathic or viral pericarditis- until symptom resolution and normalisation of inflammatory markers follwoed by tapering of dose
What is pneumothorax?
- Condition characterized by the accumulation of air in the pleural space, resulting in the partial or complete collapse of the affected lung.
How do you classify pneumothorax?
- Primary spontaneous- no underlying lung disease, often tall, young and thin individuals and associated with rupture of subpleural blebs or bullae
- Secondary spontaneous pneumothorax- pre-existing lung disease
- Traumatic- penetrating or blunt chest trauma
- Iatrogenic e.g. thoracocentesis, central venous catheter placement, ventilation incl NIV or lung biopsy
What is catamenial pneumothorax?
- Cause of 3-6% of spontaneous pneumothroaces
- Endometriosis within the thorax
Clinical features of pneumothorax?
- dyspnoea
- Chest pain- often pleuritic
Signs in pneumothorax?
- hyper-resonant lung percussion
- reduced breath sounds
- reduced lung expansion
- tachypnoea
- tachycardia
What is tension pneumothorax?
- May occur following thoracic trauma when a lung parenchymal flap is created.
- This acts as a one way valve and allows pressure to rise.
- severe pneumothorax resulting in the displacement of mediastinal structures that may result in severe respiratory distress and haemodynamic collapse.
Features of tension pneumothorax?
- tracheal deviation away from the side of the pneumothorax
- Reduced air entry on the affected side
- Increased resonance to percussion on the affected side
- Tachycardia
- Hypotension
Inv in tension pneumothorax?
NO TIME! CLINICAL DIAGNOSIS- NEED NEEDLE DECOMPRESSION
Managment of tension pneumothorax?
- Large bore cannula into the 2nd IC space, mid clavicular line on the affected side
- HOWEVER: up to date ATLS guidelines say: 4th or 5th IC space anterior to the midaxilary line
How to manage a primary pneumothorax
Remember: no underlying lung disease
- if the rim of air is < 2cm and the patient is not short of breath then discharge should be considered
- otherwise, aspiration should be attempted
- if this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted
Secondary pneumothorax management?
- if the patient is > 50 years old and the rim of air is > 2cm and/or the patient is short of breath then a chest drain should be inserted.
- otherwise aspiration should be attempted if the rim of air is between 1-2cm. If aspiration fails (i.e. pneumothorax is still greater then 1cm) a chest drain should be inserted. All patients should be admitted for at least 24 hours
- if the pneumothorax is less the 1cm then the BTS guidelines suggest giving oxygen and admitting for 24 hours
Recurrent pneumothorax managment?
- Video assissted throacoscopic surgery (VATS) should be considered to allow for mechanical/ chemical pleurodesis +/- bullectomy
(removes air bubble trapped and forms adhesion between lung and pleura)
Discharge advice for pneumothorax?
- SMoking- stop smoking
- Fitness to fly- BTS advise 1 week post check xray
- Scuba diving- permantly avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan post op
What moderate acute asthma?
PEFR 50-75% best or predicted
Speech normal
RR < 25 / min
Pulse < 110 bpm
What is severe acute asthma?
PEFR 33 - 50% best or predicted
Can’t complete sentences
RR > 25/min
Pulse > 110 bpm
What is life-threatening acute asthma?
PEFR < 33% best or predicted
Oxygen sats < 92%
‘Normal’ pC02 (4.6-6.0 kPa)
Silent chest, cyanosis or feeble respiratory effort
Bradycardia, dysrhythmia or hypotension
Exhaustion, confusion or coma
if a pt has one of above- they have life threatening asthma
What is near fatal asthma?
- characterised by raised pCO2 and/or requiring mechanical ventilation with raised inflation pressures
When do you do an ABG for patients with asthma?
- O2 sats < 92%
When is a cxr indicated for asthma?
- Life-threatening asthma
- suspected pneumothorax
- failure to respond to treatment
When do you admit a patient who is having an asthma attack?
- All pts with life-threatening asthma
- severe asthma if they fail to respond to treatment
- previous near-fatal asthma, pregnancy, attack despite already using oral corticosteroid
- Presentation at night
How do you manage an acute asthma attack?
- Oxygen sats target 94-98
- high-dose inhaled SABA e.g. salbutamol, terbutaline
-in patients without features of life-threatening or near-fatal asthma, this can be given by a standard pressurised metered-dose inhaler (pMDI) or by an oxygen-driven nebulizer
-in patients with features of a life-threatening exacerbation of asthma, nebulised SABA is recommended - Corticosteroid- all pts should be given 40-50mg of prednisolone orally daily until at least 5 days or when the pt recovers, continue normal inhaled steroids
- Ipratropium bromide- in pts with severe or life-threatening asthma or in pts who have no respondes to SABA and steroids
- IV Magnesium sulphate- severe or life-threatening asthma
- IV aminophylline- speak to senior staff
- If all this fails- speak to ITU/HDU and may need Intubation and ventilation or ECMO
Acute asthma discharge criteria?
- been stable on their discharge medication (i.e. no nebulisers or oxygen) for 12–24 hours
- inhaler technique checked and recorded
- PEF >75% of best or predicted
- Been on discharge medication for 12-24 hours and have had inhaler technique checked and recorded.
Prior to discharge, been referred to the respiratory nurse specialists for education and inhaler technique if they have been admitted with a new diagnosis or exacerbation of asthma.#
PEF > 75% of best or predicted and PEF diurnal variability < 25% unless discharge is agreed with respiratory physician (for normal peak flow diagram see SIGN 158, Annex 5 in full asthma guideline).#
Treatment with oral (prednisolone 40-50mg until recovery - minimum of 5 days) and inhaled steroids in addition to bronchodilators. Patients should have inhaled corticosteroid therapy started if new diagnosis or treatment increased if poorly controlled prior to admission. This will usually be guided by respiratory nurses. For guidance on inhaler choice see the GGC Adult Asthma inhaler device guide.
Own peak flow meter and written asthma action plan.#
GP follow up arranged within 2 working days.
Follow up appointment in respiratory clinic within 4 weeks.
What is pneumonia?
- Infection of the lung tissue causing inflammation in the alveolar space
- Consolidation on cxr
What is aspiration pneumonia?
- Infection develops due to aspiration of food or fluids
- in pts with impaired swallowing
- associated with anaerobic bacteria
Presentation of pneumonia?
- Cough
- Sputum production
- Shortness of breath
- Fever
- Feeling generally unwell
- Haemoptysis (coughing up blood)
- Pleuritic chest pain (sharp chest pain, worse on inspiration)
- Delirium (acute confusion)
Characteristic signs of pneumonia in the chest on examination?
- Bronchial breath sounds (harsh inspiratory and expiratory breath sounds) due to consolidation around the airways
- Focal coarse crackles caused by air passing through sputum in the airways
- Dullness to percussion due to lung tissue filled with sputum or collapsed
Sepsis signs secondary to pneumonia?
- Tachypnoea (raised respiratory rate)
- Tachycardia (raised heart rate)
- Hypoxia (low oxygen)
- Hypotension (shock)
- Fever
- Confusion
Outline CURB-65
C – Confusion (new disorientation in person, place or time)
U – Urea > 7 mmol/L
R – Respiratory rate ≥ 30
B – Blood pressure < 90 systolic or ≤ 60 diastolic.]
65 – Age ≥ 65
What is CURB-65?
Severity assessment for pneumonia
What does the scoring on the CURB- 65 outline?
Score 0/1: Consider treatment at home
Score ≥ 2: Consider hospital admission
Score ≥ 3: Consider intensive care
Causes of pneumonia?
i.e.organisms
Main causes:
Streptococcus pneumoniae (most common)
Haemophilus influenzae
Other causes:
Moraxella catarrhalis in immunocompromised patients or those with chronic pulmonary disease
Pseudomonas aeruginosa in patients with cystic fibrosis or bronchiectasis
Staphylococcus aureus in patients with cystic fibrosis
Methicillin-resistant Staphylococcus aureus (MRSA) in hospital-acquired infections
Atypical causes of pneumonia?
- Legionella pneumophila
- Mycoplasma pneumoniae
- Chlamydophila pneumoniae
- Coxiella burneteil
- Chlamydia psittaci
Inv for pneumonia
- cxr
- intermediate or high- risk NICE recommend blood and sputum cultures, pneumococcal and legionella urinary antigen tests
- CRP monitoring is recommended for admitted pts to help determine response to treatment
Management of low-severity CAP?
- amoxicillin is first line
- if pen allergic use macrolide or tetracycline
- 5 day course
Management of moderate severity CAP?
- dual abx therapy is recommended with amoxicillin and macrolide
- 7-10 day course
*
NICE guidelines:
* Prescribe oral amoxicillin 500 mg three times a day for 5 days (higher doses can be used — see the BNF) and (if atypical pathogens suspected) oral clarithromycin 500 mg twice a day for 5 days, or oral erythromycin (in pregnancy) 500 mg four times a day for 5 days.
* Alternatively, in penicillin allergy, oral doxycycline 200 mg on the first day then 100 mg once a day for 4 days (total course of 5 days), or oral clarithromycin 500 mg twice a day for 5 days.
Management of high- severity CAP?
- Beta lactamase stable penicillin e.g. co-amox, ceftriaxone or piperacillin with tazobactam and macrolide
- 7-10 days
Discharge criteria and advice post-discharge for pneumonia?
NICE recommend that patients are not routinely discharged if in the past 24 hours they have had 2 or more of the following findings:
* temperature higher than 37.5°C
* respiratory rate 24 breaths per minute or more
* heart rate over 100 beats per minute
* systolic blood pressure 90 mmHg or less
* oxygen saturation under 90% on room air
* abnormal mental status
* inability to eat without assistance.
