Acute Medicine - Chest pain Flashcards
3 ddx in older adults that are dangerous?
MI, dissecting aortic aneurysm, PE
possible areas of radiation in pain for AMI
back
neck
jaw
left arm
difference between angina and AMI
angina pain is reversible by GTN, rest while AMI is not
GI condition that can be confused with angina
oesophageal spasm
Mr TB, aged 45, labourer
2 weeks retrosternal discomfort radiating to throat & jaw. Precipitated by exercise or after a heavy meal. Relieved within a few minutes by rest
O/E: NAD
Angina
Mrs WA, aged 60, musician
Severe ‘crushing’ retrosternal pain of 45 minutes duration, vomiting, sweating and anxiety.
O/E: pale, clammy, dyspnoea, restless and apprehensive. Pulse and BP normal.
AMI
Mr LN, aged 65, surgeon
Sudden onset, severe ‘tearing’ retrosternal and interscapular pain. Radiates to abdomen. Sweating and anxiety
O/E: unequal pulses (between carotid and femoral)
BP 200/115
dissecting aortic aneurysm
Mrs JH aged 54, nurse
Sudden onset dreary dull retrosternal pain and dyspnoea. Associated “blackout”, sweating, agitation.
O/E: R 25/min, P 190/min
BP 90/60
PE
Mr WZ aged 49, farmer
Gradual onset (over hours) of pleuritic chest pain aggravated by coughing and deep inspiration. Preceding flu like illness. Fever, malaise.
O/E: R 22min, P 95/min,
BP 90/65
Friction rub over heart
viral pericarditis
Mr WP aged 23 soldier
Sudden onset right sided. Moderate chest pain while riding bicycle.
Pleuritic type sharp stabbing pain. Associated dyspnoea. PH: Asthma
O/E: R 28, P 92, BP 110/80
Chest: hyper-resonant to percussion, decreased breath sounds.
Pneumothorax
Mr GS aged 59, salesman
Recurrent episodes of epigastric and retrosternal burning pain radiating to neck and sometimes to back. Pain aggravated by bending over and after retiring to bed. Precipitated by heavy meals and wine
GORD
Mr LH aged 55, hairdresser
Recurrent episodes of pain in back of chest with radiation around chest wall. Aggravated by deep breathing and exertion. Pain is dull and aching
O/E: tenderness over T5 & T6 vertebrae
spinal dysfunction
Mrs SB aged 41, flight attendant
Recurrent episodes of left side precordial and submammary discomfort. Usually a dull pain with stabbing episodes.
O/E: NAD
costochondritis
3 days very sharp severe pain which goes around the chest wall on right side. The pain does not cross the midline. Not pleuritic in nature.
O/E: NAD
shingles
what is the acute management of asthma?
DRABC
Murtagh’s rule: O2, IV, measure vital signs
salbutamol 5mg nebulized continuous and ipratropium 500mcg nebulized (once)
hydrocortisone IV 100 - 250mg
further investigation CXR for pneumothorax
if not progressing –> consider IV salbutamol, consider IV adrenaline 0.5mg IM if not progressing
what is the acute management of hypoglycemia
DRABC
O2, IV, Measure and monitor vitals
if severe: give 50% dextrose (50mg) IV or glucagon 1mg IM
what is the acute management of MI
DRABC O2, IV, measure and monitor vitals (MONASH) morphine - 2.5 - 5mg IV and metoclopramide 10m IV (PRN) O2 100% GTN sub lingual Aspirin 300mg Streptokinase/thrombolyse if less than 90min away from hospital Heparin IV
acute airway obstruction
DRABC
assess severity of upper airway obstruction
if partial obstruction, encourage coughing
if full obstruction, 5X back thrust, 5X sharp chest press
if unconscious, empty throat with finger sweep, start CPR
acute intoxication/narcotic overdose
DRABC
(first line) naloxone 0.4g IM
followed by naloxone 0.2 - 0.4 mg IV, PRN
what is the treatment of acute anaphylaxis
DRABC
position legs supine
IV adrenaline: 0.3 - 0.5 mg IM (adult) to lateral thigh and repeat every 3 - 5 minute
10mcg/kg IM (child) to lateral thigh and repeat every 3 - 5 minute
give IV N. Saline
if patient is experiencing:
stridor = adrenaline 5mg/5ml nebulized
bronchospasm = salbutamol 5mg neb and 250mg hydrocortisone
what is the role of antihistamines in anaphylaxis?
there is no role
what is the tx of a snake bite?
DRABC
murtagh’s law: IV, O2, Monitor vitals
assess for signs of envenomation such as: coagulopathy, neurotoxic muscle paralysis, muscle damage causing renal failure
treat wound
if significant envenomation –> refer and start IV anti venom
what is the tx of the status epilepticus
DRABC, send for help
murtagh’s law; o2, iv, mm vital signs
support c-spine
give immediate benzodiazepine IV - 0,2mg/kg IV diazepam, midazolam 0.1mg/kg IV
if unresponsive, give 15mg/kg IV over 30 minutes w/ a loading dose
what is the tx of severe migraine
DRABC
murtagh’s law: O2, IV, MM vital signs
IV normal saline 500ml stat followed by N saline 500 - 1000ml over next 1 - 2h
give chlorpromazine 12.5mg IV for anti emetic
what is the tx of potential meningococcal septicemia
DRABC
murtagh’s law: o2, iv, mm vital signs
dexamethasone 10mg OR hydrocortisone 200mg IV before antibiotics
benpen I.V 60mg/kg or IM up to 2.4g max
ceftriaxone 100mg/kg IV or IM up to 4.0g max
obtain cultures if possible but do not delay antibiotics
