Chest Pain Flashcards
Approaching the Pt. with Chest Pain
always assume the worst until you can convince yourself and prove its not that
- get the EKG and see them ASAP
- watch your aypical presenters: women and teh eldery and teh diabetic
Primary Survey
- ABCs
- patient apperance
- VS; get O2 sat.
- place an IV line: adminiser O2 if needed
- EKG within 10 minutes of arrival for “chest pain” pt.
- get a full pulm and cardiac PE
Seondary
- get further history
- pain relief
- consider labs, serial EKG and imaing if needed
History Key Points
- “Classic Cardiac”
- Nonclassic presentation
History
- location, medical history, other symptoms, quality, radiation, severity, timing of symptoms
- radiation to neck, jaw, arm or shoulder is concerning for cardiac
- radiation to the back: aortic dissection sus
“Classic Cardiac”
- retrosternal chest crushing squeezing pain
- worse with exertion, better with rest
- angina: 2-10 minutes, untable 10-30 minutes, AMI will be longer than 30 mins
- pain to the jaw, arm, etc.
“Nonclassic”
- constant pain that does not wax/wain
- stabbing pain, pleurtic = less liekly
- women, racial monorties, diabetic, elderly and AMS pts.
- meds can impact someones perception to pain!!
Women
- pre and early menopause
- pain unrelated to exercise, not relieved by rest and FATIGUE
alwasy watch for angial equlivents
epigastric pain not relieved by antacids should raise suspicison for ACS
Physical Exam for a Chest Pain pt.
what PE to do
what imaging
what labs
always reassess your pt. things change fast
VITALS = NEED
PE for…
- skin
- cardiac/pulm.
- carotids/JVP
- abdomen
- extremities
- peripheral pulses
EKG
- get within 10 minutes of arrival
- usually normal; but that doesnt r/o ACS
- repeat or keep on monitor
Imaging get all because you just dont know
- CXR
- CT angiogram
- V/Q scan (lungs)
Labs
- CBC & CMP
- Cardiac Enzymes: cardiac troponins (CK-MB not favored)
- consider BNP for CHF or PE pt. because when heart too full BNP produced
- TSH! with reflex T4 (mimic)
note on troponins: they will rise typically highest 1 day after the onset of teh AMI and then fall
Consider…
-D-Dimer if you think PE & Wells/PERC for DVT
- coags: to see bleeding profile
- urine drug
- pregnancy test for all females of CBA
Palpitations
what are they
described as what
Palpitations
- the experience of feeling the heart pounding, racing
- heartbeat feels irregualt or praid
described as
- “ skipping a beat”
- felt in neck, thraot or chest
PACs& PVCs
PAC: premature atrial contraction (arrythmia)
- the heart beats prematural due to an early signal from the atria
- area within the atria is beating before the SA node has tirggered the next beat
Who
- common in healthy young pt. and elderly
Treatment
- no treatment needed
- just reassurance
______________________________________
PVC: premature ventricualr contractions
- the beat is initiated by the perkinje fibers in the ventricle before the SA node is ready
- a single PVC is not a big deal
- but PVCs can be a sign of hypoxia, MI or hypokalemia
- often asymptomatic but can be felt like heart is skipping a beat
Arrythmias: SVT
Paroxysmal supraventricaulr tachycardia: SVT
- most frequently due to the sustained reentry of an electrical impulse within the AV node - cycles through and continuous gives this signal to fire and fire and fire
- females & usually those without cardiovascualr disease
Treatment
- the beat is too fast: we need to slow down
- 1st: try vagal maeuvers
- if that fails, can give adenosine to slow it down
- remember adenosine feels so awful: warn pt.
Atrial Fibrillation
what is it
EKG sign
association
treatment
What is A fib
- small areas within the atria are consistenlty firing their own electrical signal without a rhythm, thus no uniform contraction occuring
- this results in quivering atrial walls, leading to poor ventricualr filling & dimished cardiac output
EKG
- you will see a wavy “baseline” (no disernable P wave) with irregualarly irregular rhythm of the ventricules
Association
- a fib = increased risk of stroke
- assocaited with those who have ischemic or valvualr heart disease
- “holiday heart (binge drinking)”, thyroid issues, cardiomyopathy,etc.
Symptoms
- fatigue
- fulltering chest
- dizzy
- SOB
- chest pain
Treatment
- in the ED: three steps
- 1. control the ventricular rate
- 2. convert the rhythm
- anticoagulate them to prevent emobli
Ventricualr Tachycardia
what is it
EKG appearance
who gets it
management
What is it
- three or more consecutive depolarizations from a ventricualr etopic foci - of which the rate they are firing is > 100 BPM
Monomorphic: (one foci)
- “gravestone appearance”
- a very regualr rate with beats 140-180
Polymoprphic: multiple foci
- a variety of QRS morphologiies
- Torsades: a type of Vtach which comes from a prolonged QT interval
Who gets Vtach
- those with underlying heart conditions
- chronic ischemic heart disease
- acute MI
Management = depends on pt. stability
Angina :Stable Angina:
what is it
Symptoms
treatment
Stable Angina: you wont see in the ER because theres no “problem”
what
- episodic myocardial ischemia
Symptoms
- epidosde of chest discomfort
- come on then wear off in nature
- last 2-5 minutes
- resolve with rest or nitroglycerin
Unstable Angina
what is it
symptoms
Signs
What is it
- changes in the pattern of the pt. previous angina symptoms
- chest pain from inadequate perfusion of the myocaridal tissue that is new or changing from baseline
Symptoms
- not relieved by rest
- changing in paain
- occuring more frequently
- less activity provokes it
Signs
- there will NOT be any ST segment elevation on EKG or any signs on cardiac bimarkers of ischmia
- but theyre at risk of this developing into damange
Unstable Angina
types
how to go about treatment (HEART score)
Types
- Rest Angina: angina occuring at rest or prolonged > 20 mins
- New-onset angina: cahnge and limitied physical activity
- increasing: previously dx. and now its more often and lasts longer
- Prinzmetal: focal coranary vasospams : occuring at rest/wakes pt. up at night +/- transient ST elevation
HEART Score
- helps to use in any pt. 21+ with ACS symptoms needing a workup to help see and rank them on severity and lieklihood of having a MACE in the next 6 weeks
- dont use this on those with ST changes evident on EKG: you already know wahts going on
Low Risk : 0-3
Moderate: 4-6 (admitted)
high: 7+ (admitted and possible interveined with)
ACS
define and waht does it include
ACS: acute coronary syndrome
- ischemia occurs due to imbalance in o2 delveiry and demand in the heart
- includes: unstable angina —> Acute MI
- can be due to, arterial vasospams, plaque traveled there or platelet aggregation/thromobus formation at the site itself
AMI
what is it
EKG changes
symptoms
AMI : acute myocardial infarction
- myocaridal necrosis due to arterial occlusion
- evidence of elevated biomarkers
- EKG findings of…
- STEMI: ST segment elevation
- NSTEMI: non-ST segmenet elevation
Symptoms
- retrosternal chest pain that is tight, crushing, squeezing
- radiation of pain to jaw, shoulder, arm or neck
- sweating, SOB, N/V
- exacerbated by activity and better with rest
- can be atypical presenations too–remember
Signs
- PE usually normal
- hypotension, S3 gallop and sweating usually accompany MI
AMI
Specific EKG Changes that you will see
Lab Values
EKG Changes
ST segement elevation
NSTEMI: including….
- ST depression
- inverted T waves
- new LBBB
- LVH with repolarization abnormality (strain)
Lab values
- troponins & CK-MB
- but, they may initially be negative since it takes while; this doesnt r/o an AMI
AMI
Treatment for STEMI
Treatment
______________________________________
- asprin: CHEWED
- clopidogrel or ticagrelor (ticagrelor preferred)
- Nitroglycerin: watch out….
- men on PDE-5: cant take nitro
- can make inferior wall MI worse
- caution in hypotensive or bradycardic pt. can bottom out
- give Beta Blockers
- antithrombin: heparin, enoxaparin
- morphine prn pain
- O2 if needed
__________________ where to go________________
- STEMI: percutaneous cornary intervention: cath. lab
- want them to the lab within 90 mins, if you need to send elsewhere; within 120 mins
- fibrinolyic thearpy within 30 mins of arrival if PCI cannot be done in time
