chest pain Flashcards
ftx of chostochondritis
self remitting goes away in a few weeks
but NSSAIDS if really bad you can get steroid injections
chostrochondritis
inflammation of the costal cartialage
causes of chostrochondritis
trauma
athletes - constantly straining
recent infection - coughing loads
repitive movements like lifting jobs
coughing a lot, like smoker
or an actual infecton
some rheumatoid diseases can affect sometimes like SLE, RA
symptoms of chosto chondro
inhaling deeply
chest pain - central
coughing, laughing hurts
lying down hurts
how would you diagnose chostochronditis
clinically
tender on palpation
somoen comes in with chest pain what ddx do you not want to miss
- MI
- PE
- PNEUMOTHORAZ
- AORTIC DISECTION
signs of arotic dissection
its qtie varied as the aorta is a wide vessel so any organ can be affcected
- chest paon
- abdo
- back pain
- tingling and numbness of extremities
- cold extremtiies
- radio radio delay
7 radio femoral delay
rf for dissection
ct diseases
hypertension
aneurysm (weakens wall)
defintive diagnosis aortic dsscetion
CT ANGIOGRAM (looking at the vessels just like in pulmonary embolism )
how can we categorise the causes for chest pain
- CARDIAC
- RESP-pe, pneumothoraz
- OESAPHAGEAL
- CHEST WALL PAIN
investigations
bloods -anemia can be a cause, pericarditis
ecg
xray - if s.o.b
HEART SCORE is for what
likelhood of major caridac event
patient comes in with chest pain what do you want to make sure you do
troponin - NB
ecg - NB!
CXR - depending on history
Check pulses - AD
murmours
whast the difference in pain between ACS and AS
AD- very sudden tearing reaches maximum immediately
anterior cp- if ascending aorta
back pain - if descending
abdo - if mesenteric
strok symptoms - if brain vessels
ACS- gradually builds up in minutes
what do we mean by ACS equivalents
not all patients present with the classic chest pain so look out for the hidden signs
- unexplained sweating
2 . epigastric, indigestion - shoulder, arm pain
who are the groups who typically present atypically for ACS
women
elderly
diabetics
so be careful of
nausea /vomiting
s.o.b
dizziness
jaw neck pain
why do we do repeat ecgs
because for instance the first ecg may be normal but the patient has someting goin on so if you still suspect something dodgey it doesnt hurt to repeatt
allows you to monitor
what helps with the pain in chest pain and why do we treat the paiin in ACS
nitrates and morphine
pain increases the demand
examples of antiplatelets
prasigruel
clopidogrel
ticagrelor
what is dual antiplatelet therapy you can consider (nice ) for STEMI
ASPIRIN
PRASUGREL (if not already taking anitocagulants as high bleeding risk )
clopidgrel (if on antiaogulatns already )
out of prasigurel and clopidogrel which has the highest risk
prasugrel which is why you only give in ACS if pt is not already on anitaocgulants
what is fondaparinox
LMWH
is it alone in STemi To give dual antiplatelet theray yfor pci
No you need anticoagulant too as its working on different things,
pci will cause damage to vessels which can activate the cascade so need antithrombin therapy for during the procedure.
when do you give thromobolysis as oppose to pci
when you cant make the time window within 2 hours
which do we prefer pci or thrombolyis and why
pci - less bleedinf risk esp ICH hemorrage
mosr succesful at removing the occulusion and preventing reoccurane
CI to thrombolyis
whats the biggest thing we are worried about with thrmobolyis
bleeding diatheis
activiley bleeding (except menses)
Aortic dissection
Severe uncontrolled hypertension (>180/110 mmHg).
Recent major surgery or trauma (within 3 weeks).had a stroke in past (3 months ago )
nb intracranial hemorrahe
do you do thromobolyis if symprtom onset is >12 h
generally no because the clot has been become more stabilised at this point making it harder to dissolve the clot
bleeding risk increases
neumonic for CI for hemolyis absolute
H – Hemorrhagic stroke (ever) or ischemic stroke within 3 months
A – Aortic dissection suspected
S – Severe hypertension (SBP >180 or DBP >110, uncontrolled)
B – Bleeding diathesis (active internal bleeding)
L – Low platelets (<100,000) or recent major surgery/trauma (past 3 weeks)
E – Eye problems (e.g., recent retinal hemorrhage)
E – Emergency CPR >10 min (traumatic)
D – Danger of intracranial neoplasm, aneurysm, or AV malformatio
so what if a patient presents more 12 hours after A STEMI but Pci can be delivered within the guidline timeframe
depends on if they have symptoms or not
if stilll symptomatic or ecg changes yes
if no symptoms then no manage conservatively
doses of antiplatelets you can give bonus in acs
clopidogrel same as aspirin 300
prasurgrel is 60
RF FOR MI
hypertension
diabtes
hypercholesteremia
smoking
alochol
family histry
age
why do we use heart score
likelihood of a major cardiac event happenign
Quickly risk-stratifies patients with chest pain in the Emergency Department (ED).
Helps decide whether to admit, discharge, or do further testing.
Simple, easy to use, and commonly applied in low-to-intermediate-risk patients.
0-3 (Low risk): Discharge, outpatient follow-up.
4-6 (Moderate risk): Consider stress test, further evaluation.
7-10 (High risk): Admit, urgent cardiology evaluation.
common complicatons of on MI
acute MR- pansystolic due to papiallry muslce rupture
aneurysm of wall
hole in septem - often hear a systolif murmour
dresslers
heart failure
investigations for suspected PE
- CXR-rule out pneumo, infection
2.ECG -rule out Mi - TROPONIN - eveidence of right strain hearts strain
- echo -
why order troponin in suspected PE
becayse righ heart strain and if the case then need echo
triad of pe
dyspena - most common
chest pain pleuritic
hemoptysis
signs you may observe in PE
CRACKLES !!
decreased air entry
tachy
hypo
dyspnea
slight temp is possible ! rule out infection
hypoxia
qhat happens if you do a ct pa and its negative
then consider dvt do ultrasound
if wells >4 what to do
immediate ct pa
or if going to be a while start on anticoagulation
if wells is <4
do a d dimer (within 4 hours)
or start interim coagulation
if postive - do CT PA
IF NEGATIVE -
if you cant do a ctpa whats options
v/q scan
WHAT COULD ABG SHOW IN PE
type 1 failure
resp alkolosi due to hyperventilation
signs of a massive pE and what to do
persistent hypotension despite giving fluids <90 systolic for more than 15 minutes OR A DROP IN SYSTOLIC BP OF MORE THAN 40 MMHG PE
or if in cariac arrest
because of theperistant hypotension go straight for alteplase
PESI SCORE VS WELLS
WELLS- DO THEY ACTUALY HAVE A PE
PESI - ONCE THEY DO HOW BAD IS IT
DIFFERENECE IN PAIN BETWEEN MI AND PE
MI - SQUEEZING, CRUSHING, LIKE SOMEONE SITTING ON YOUR CHEST, TIGHT
- central or to the left
PE- sharp , stabbing pain , often localised t one side of the chest , more pleuritic in nature
What is the most common ECG abnormality seen in patients with a pulmonary embolism (PE)?
TACHY
maybe s1q3t3
