Approach to Chest Pain

Question 1

ACS

1-classic presentations…?

2-Non-classic presentations occur more frequently…?

3- diagnosis …?

4-treatment …?

5-Contraindication to Nitroglycerin………?

Answer 1

ACS

1-classic presentations…?
(SOB),diaphoresis, and radiation to neck/arm/shoulder& Pain worsens upon exertion.

2-Non-classic presentations occur more frequently in women, elderly ,black race, diabetics &with psychiatric disease

3- Troponin is the test of choice for diagnosing MI. Along
with the history and ECG.

4-treatment
ABC 
IV, oxygen SpO2 >90% and cardiac monitoring.
Aspirin or clopidogrel
For pain Nitroglycerin 
Then do Percutaneous intervention (PCI).  
Or 
give Fibrinolytics.

5-Contraindication to Nitroglycerin: Hypotension ,Inferior STEMI & use phosphodiesterase inhibitors.

Question 2

PE

1-Type if PE….?

2-Presentation?

3- Diagnosis ?

4- treatment ?

Answer 2

PE

1-Type if PE
• Massive (Hypotension: SBP <90 or ⬇️ >40for 15 min &Signs of shock)

•Submassive (Myocardial necrosis -elevation of troponin ) or(Right ventricular dysfunction -echocardiographic or CT⬆️ (BNP) or ECG criteria)

2- Presentation:
• SOB, pleuritic,Tachypnea & Wells Criteria.

3- Diagnosis:
• Low to moderate risk of having PE → D-dimer.
• High risk of having PE → CT pulmonary angiogram is the test of choice.

4- treatment
• Anticoagulation
• For massive PE, thrombolytics.

Question 3

AAD

1-risk Risk factors?3

2-Classic presentation?

3-Diagnosis?

4-Therapy?

Answer 3

AAD

1- Risk factors: HTN, atherosclerosis and connective tissue disease.

2-Classic presentation is severe tearing or ripping pain
radiating to the back +neurologic complaints/findings.
+Diastolic murmur=aortic regurgitation.

3- for diagnosis CTA is the test of choice.

4- Therapy:
• Pain control. • BP control • Surgical consultation.

Question 4

Esophageal Rupture

1- Risk factor ?

2-presentation?

3- Diagnosis?

4-Therapy?

Answer 4

Esophageal Rupture

1- Risk factor : alcoholics or history of
recent procedures.

2-presentation: • Boerhaave’s syndrome. • Severe CP, forceful vomiting& subcutaneous crepitus.

3-Diagnosis:
CXR show left side pleural effusion and mediastinal
air.

4-Therapy : IV antibiotics. • Emergent surgical.

Question 5

Cardiac Tamponade

1-presentation?

2- Diagnosis?

3-Therapy?

Answer 5

Cardiac Tamponade

1-presentation: Tachycardia ,Pericardial rub ,Muffled sounds& Jugular venous distention.

2- Diagnosis : POCUS”Ultrasound”
it show diastolic collapse of the cardiac chambers.

3-Therapy: pericardiocentesis.

Question 6

Tension Pneumothorax

1-presentation?

2- Diagnosis?

3-Therapy?

Answer 6

Tension Pneumothorax

1-presentation: Shock ,respiratory symptoms & Decreased venous return to the heart.

2- Diagnosis: clinically + Don’t wait for the X-ray .

3-Therapy : Treat with needle decompression while preparing for ED Thoracostomy.