CHEST PAIN Flashcards
MANAGEMENT
INITAL MANAGEMENT: ACTIVE ISCHEMIA
A - STRIDOR.
B - RESPIRATORY RATE. >/ 30, 02 sats 90% on Fi02 30%. Work of breathing. Tracheal Position. Chest wall crepitus / chest rise.
C - MOTTLED APPEARANCE. GCS. Pallor. Cap Refill. Distal Pulses. Palpate Abdomen.
D - CHECK GLUCOSE. GCS, PERRLA, lateralizing signs
E - EXPOSURE, TAKE DOWN DRESSINGS
Place on Cardiac Monitor
IV Access if active ischemia, abnormal ECG, abnormal vital signs
12 lead ECG within 10 min & compare to previous.
Rule out STEMI vs. NSTEMI
Oxygen: As needed to keep 02 >95%
Nitroglycerin:
0.4 mg 1-2 sprays SL q5min x 3 (if SBP > 90)
OR
patch (0.4-0.8 mg/h)
OR
IV: 10 mcg / min
titrate to 10% reduction in MAP if normotensive, 30% reduction in MAP if hypertensive
C/I in HoTN, RV infarct, PDE5i
ASA:
ASA 160 mg - 325 mg chewed x 1, then 81 mg daily
C/i: Active bleeding, ASA allergy
Hydromorphone: 0.5-1 mg SQ / IV q 1 hr PRN
OR
Morphine: 2-4 mg IV, q5-30 min, max 10 mg/hr
INVESTIGATIONS:
ECG: Within 10 min. Review prehospital ECG and ECG on arrival, Compare to previous
-if ECG suggests occlusion MI; STEMI, STEMI Equivalent / STEMI -ve OMI -> STEMI Management
-if ECG suggests ischemia; ST depression, or T wave inversion, or ongoing symptoms -> serial ECG every 15 min-30 min, consider NSTEMI management
-If non diagnostic ECG but high clinical suspicion, reassess q15-30 min for ECG ischemia OR ongoing symptoms
-If non diagnostic ECG but LOW-MODERATE clinical suspicion -> serial troponin q 2 hr
Troponin
CBC
ED Basic
CXR
+/- D-dimer
+/- abdo panel
+/- CTPE
+/- CTA Chest
REASSESSMENT: LOW-MODERATE ACS
-Order Repeat 2 hr Troponin & ECG
Calculate HEART SCORE
0-3 0.9%-1.7% MACE Discharge
4-6 12-16.6% MACE Admit
>/7 50-65% MACE Early Invasive
Calculate WELL’s SCORE
Wells < 2 use PERC
Wells 3-4 D-Dimer
Wells >4 CTPE
Calculate PERC
If none and low probability, PE risk = 1.8%
REASSESSMENT: LOW-MODERATE ACS
-2-3 hr Troponin / ECG
Calculate HEART Pathway
0-3 0.9%-1.7% MACE Discharge
4-6 12-16.6% MACE Admit
>/7 50-65% MACE Early Invasive
DISPOSITION:
HEART PATHWAY < 4 - Discharge
HEART PATHWAY >/ 4 - Admit
DOCUMENTATION
HPI
DDx Sudden onset pain:
aortic dissection, pneumothorax, pulmonary embolism
DDx Sharp / Stabbing pain: thoracic aortic dissection, pneumothorax, pulmonary embolism, mediastinitis / esophageal rupture
Critical DDx:
ACS
PE
TAD
Pericarditis / Tamponade
Tension PTX
Esophageal Rupture
ACS:
Substernal chest pain with:
Worsened by exertion / emotion Relieved by rest
Improved by nitroglycerin
Radiation to jaw / neck / arms
Vomit
Diaphoresis
Similar to past (proven) ischemia / infarction
Risk Factors for Non Classic ACS Presentation:
Advanced Age
Female
Diabetes
Pulmonary Embolism:
Pleuritic Chest pain
Hemoptysis
Unilateral leg swelling
Immobilization at least 3 days Surgery in the previous 4 weeks
Previous, objectively diagnosed PE or DVT
Presence of Malignancy, treatment within 6 months or palliative
Recent long distance travel
Aortic Dissection:
Severe sharp (68%)
Ripping (50%) or tearing pain
Radiation to Back
Syncope / Pre-Syncope
Pericarditis:
Sharp / Pleuritic
Relieved sitting forward
Radiating towards the trapezius ridge (virtually pathoognomonic)
Recent URI / Illness
Esophageal Rupture:
Dysphagia / Odynophagia
Sharp / Stabbing Pain
Forceful vomiting
MSK:
Tender (to palpation)
Recent trauma, strenuous activity, drug use (EtOH, sympathomimetics), illness
RISK FACTORS:
CAD / CHF / Arrythmia
PE / DVT
PVDZ
Age
Smoking
HTN
DM
Chol
FHx
Obesity
PHYSICAL EXAM:
PPP
2/4 limb BP
Chest: emphysema
Unilateral absence of breath sounds (pneumothorax)
Rhonchi (infection)
CVS:
New murmur or rub
elevated jugular venous pressure, bilateral lower extremity swelling/dependent edema, Unilateral leg swelling
Unequal pulses
Abdominal exam: pulsatile mass, tenderness to suggest biliary or pancreatic etiology, lack of epigastric tenderness if patients with inferior MI presenting as epigastric pain)
Neurologic deficits: (consider thoracic aortic dissection)
Reproducible chest pain
ECG: Check for
Ischemia
PE
Pericarditis
HEART SCORE
0-3 0.9%-1.7% MACE Discharge
4-6 12-16.6% MACE Admit
>/7 50-65% MACE Early Invasive
WELL’s SCORE
Wells < 2 use PERC
Wells 3-4 D-Dimer
Wells >4 CTPE
PERC
If none and low probability, PE risk = 1.8%
REASSESSMENT
-Chest Pain
-Vitals
-Repeat Troponin
-Repeat ECG
DISPOSITION:
HEART PATHWAY </3 - Discharge
HEART PATHWAY >/ 4 - Admit
ECG: ST ELEVATION
DDx: Diffuse ST Elevation
STEMI
pericarditis
coronary vasospasm
ventricular aneurysm
BER
Raised Intracranial Pressure
DDX: Peaked T Waves
Acute pericarditis
Hyperkalemia
Early acute myocardia ischemia
LVH
BER
RBBB
Pre-excitation
ST-ELEVATION
(Use the J point, 2 contiguous leads)
Men > 40 yo: 2mm in v2-V3 and >/ 1 mm in all other leads
Men < 40 yo: 2.5 mm in v2-v3 and >/ 1 mm in all other leads
Women: 1.5 mm in v2-v3 and >/ 1 mm in all other leads
ST-Segment Elevation in non-AMI vs. AMI:
Draw a line from the J point to the apex of the T-wave
non-AMI: ST-segment-T-wave complex is concave
AMI: ST-segment-T-wave complex is convex or flattened (“bulging upward”)
ECG: STEMI EQUIVALENTS
- Smith-Modified Scarbossa Criteria
Concordant STE >/ 1 mm in >/ 1 lead
Concondant STD >/ 1 mm in >/ 1 lead of V1-V3
Proportionally excessive discordant STE in >/1 lead anywhere with >/ 1 mm STE, as defined by >/ 25% of the depth of the preceding wave - Sgarbossa Criteria
A. Concordant ST elevation >1 mm in leads with a positive QRS (5 pts)
B. Concordant ST depression >1 mm in v1-v3 (3 pts)
C. excessively discordant ST elevation >5 mm in
leads with a(-)ve QRS complex (2 pts)
These criteria are specific, not sensitive (36%). Score of >/3 is 90% specific
- Wellen’s Sign
Type A (25%) - Biphasic t wave pattern (initial positivity, terminally negative) in V2-3 (may extend to V1-6)
OR
Type B (75%) - Inverted t wave in V2-3 (may extend to V1-6)
PLUS
ECG pattern is present in a pain free state
May evolve from a Type 1 to Type B over time.
A recent history of chest pain (resolved)
Signifies a Critical LAD occlusion
Inverted T waves are a marker of reperfusion and may occur after an aborted anterior STEMI
Patient’s may be pain free and with minimally elevated or normal cardiac enzymes
patients are at risk of sudden LAD re-occlusion leading to massive anterior STEMI, require invasive therapy
Re-occlusion of the LAD will lead to normalization of the t waves (“pseudo-normalization”) and evolve into a STEMI
Require serial ECG’s
Needs percutaneous cornary intervention
NOT responsive to Medical management
- De Winter’s T Waves
Tall symmetric peaked T waves in V1-6
WITH
Upsloaping ST depression > 1 mm at the J point in V1-V6
Absence of ST elevation in the precordial leads
Reciprocal ST segment elevation (0.5mm-1mm) in aVR
Proximal LAD Occlusion
~2% of acute LAD occlusions
STE: Anterior, Reciprocal changes, Clinical Significance
ST Elevation in precordial leads V1 - V6) +/- High Lateral Leads with subsequent q wave formation
Changes usually preceded by hyper acute t waves
Reciprocal st depression in inferior leads (mainly III and aVF)
The magnitude of reciprocal change in inferior leads is determined by the magnitude of ST elevation in I and aVL (as these leads are electrically opposite III and aVF), and hence may be minimal or absent in anterior STEMIs that do not involve high lateral leads.
LAD. Poorest prognosis.
STE: Inferior, Clinical Significance, RCA vs. LCx Features
STE in leads II, III, and aVF
Hyperacute T waves may preceed these changes
Reciprocal depression in aVL
Progressive Q wave development in II, III, and aVF
RCA (80%),STE III>II, STD I, signs of RV infarction
LCx (18%), STE II = III, NO STD I, signs of lateral infarction
Associated features with Inferior STEMI that confer poor prognosis:
Concomitant right ventricular infarction (40% patients)
Significant bradycardia due to 2nd or 3rd degree heart block
Posterior Infarction due to extension of infarct area
DO NOT IGNORE aVL!!! MAY BE THE ONLY FINDING
STE: Right Ventricle, Clinical Significance
ST-segment elevation V1
ST-segment elevation V1 > V2
ST-segment elevation in V1 and ST-segment depression in lead V2
Isoelectric ST-segement V1 and marked ST-depression in V2
ST elevation in III > II
Complicates up to 40% of Inferior STEMI.
Diagnosis confirmed by presence of ST elevation in the right-sided leads (V3R-V6R). The most useful lead is V4R.
ST elevation in V4R has a sensitivity of 88%, specificity of 78% and diagnostic accuracy of 83% in the diagnosis of RV MI
Preload sensitive, can develop severe hypotension in response to nitrates. Treat with fluid loading. Nitrates c/i.
Posterior MI
Horizontal ST dep v1-v3 (the right precordial leads)
Prominent R waves (R/S ratio > 1) and upright T waves in V1-V3
If ST depression >=0.5 m in v1-v3 do posterior leads
ST elevation >= 0.5 mm in V7-V9
Flipped T in aVL (reciprocal of inf/RCA MI)
ACS MIMICS
PERICARDITIS
Stage 1 – widespread STE and PR depression with reciprocal changes in aVR (occurs during the first two weeks)
Stage 2 – normalisation of ST changes; generalised T wave flattening (1 to 3 weeks)
Stage 3 – flattened T waves become inverted (3 to several weeks)
Stage 4 – ECG returns to normal (several weeks onwards)
STEPWISE APPRAOCH: STEMI vs. PERICARDITIS:
1. Factors that strongly favour STEMI:
i. STD except in V1 or aVR: ignore V1 or aVR
ii. STE in III>II
iii. Horizontal or convex upwards STE or checkmark signs NOT concave
Factors strongly favouring AP:
v. friction rub
vi. Downsloping or PR depression in multiple leads (only reliably seen in viral AP, transient, NOT PATHOGNOMONIC)
Additional factor favouring STEMI:
iv. R-T signs (checkmark sign)
Additional factor favouring AP:
vii. Spodick sign: downsloping of T-P segment
ECG: PULMONARY EMBOLISM
1) Sinus Tachycardia
2) Right Axis Deviation
3) Incomplete or complete RBBB
4) Right Ventricular Strain Pattern:
T wave inversion anteroseptal leads > inferior
-PE
-Wellen’s
-SAH
5) S1, Q3, T3 Pattern:
Large S wave in lead I
Small Q wave in lead III
Inverted T wave in lead III
6) ST Elevation in aVR
-PE
-really bad MI
DDX: DEEP INVERTED T WAVES ANTERIOR LEADS “BSWAMP”
Brugada Syndrome
- treat arrhythmia, cardiology consult
Subarachnoid hemorrhage - neurosurgical consult
Wellens syndrome - aspirin cardiology consult
Arrhythmogenic Right Ventricular Dysplasia (ARVD) - cardiology consult
MI - PCI or thrombolysis
Myocarditis/pericarditis - supportive, non-steroidal, colchicine
PE - anticoagulation, thrombolysis, thrombectomy
