Chest Pain

Question 1

Dx tests for acute MI:

Answer 1

Physical Exam
ECG
Cardiac Markers

Question 2

Pros and cons of the different cardiac markers:

Answer 2

CK-MB = >90% sensitive for MI 5-6h after symptom onset, but only 50% sensitive shortly after presentation, elevate @ 3-12 hours, peak @ 18-24 hours, duration 2 days

Troponin = Tn-I similar to CK-MB but duration is 5-10 days; TN-T is less sensitive, but is an independent marker of CV risk

Question 3

Treatment for patient with ACS:

Answer 3

“OH BATMAN Mneumonic:

Oxygen
heparin
beta-blocker
aspirin
thrombolytic
morphine
anti-platelet agent
nitrates

Question 4

Examples of common anti-platelet agents:

Answer 4

Plavix

Question 5

MOA of Aspirin

Answer 5

Irreversibe antiplatelet agent

Inhibits thomboxane A2 and therefore blocks platelet aggregation

Question 6

MOA of nitrates:

Answer 6

Decrease preload + afterload through massive vasodilation

Increases coronary perfusion

Question 7

Role of ß-blocker in ACS

Answer 7

decrease infarct size, CV complications, and mortality

Question 8

When fibrinolytics are indicated in AMI:

Answer 8

if ST elevation > 0.1mV in 2+ continguous leads

Or There is a new LBBB

Time to therapy < 12 hours (class I), 12-24 hours (class IIb)

Question 9

Types of cardiac issues associated with cocaine:

Answer 9

6% of patients w/ cocaine-associated chest pain have an AMI (often atypical chest pain)

20-60% have transient myocardial ischemia

Question 10

Onset of cardiac symptoms in cocaine use:

Answer 10

Can be delayed hours to days after most recent use

Question 11

Etiology of cardiac issues with cocaine:

Answer 11

spasm
inc. myocardial O2 demand
clot formation
accelerated atherosclerosis w/ LVH

Question 12

Diagnosis of cocaine related chest pain:

Answer 12

History
Tn-I useful

ECG is less sens/spec than for MI
CK-MB less sens

Question 13

Prognosis for cocaine related chest pain:

Answer 13

Favorable short term

Higher 1 year mortality due to associated comorbidities or cont. cocaine use

Question 14

Treatment for cocaine related chest pain:

Answer 14

Benzos

AVOID ß-blockers (unopposed alpha agonism can result in vasospasm)

Question 15

What is an aortic dissection?

Answer 15

intimal tear w/ entry of blood into media, dissecting btw. intima and adventitia

Question 16

Most important risk factors for aortic dissection:

Answer 16

**HTN**
Age over 50
Ehler-Dahlos
Marfan's
Pregnancy
Bicuspid aortic valve

Question 17

Prognosis of type A and B thoracic aortic dissections with or without surgery:

Answer 17

Mortality of A = 75% if untreated, 15-20% if sx

B = 32-36% w/ or w/out surgery

Question 18

Patient presentation in thoracic aortic dissection:

Answer 18

abrupt + severe pain in the chest (type A) or mid-back (type B), “tearing” or “ripping”, can be dull or pressure-like, N/V and diaphoresis common

Involved areas and associated symptoms:
Carotid arteries: stroke
Spinal arteries: paraplegia
Abdominal aorta / renal arteries / iliacs: Abdominal / flank pain
Coronary arteries: aortic insufficiency; pericardial effusion/tamponade
Laryngeal nerve compression: hoarseness
Tracheal compression: dyspnea / stridor / wheezing
Esophageal compression: dysphagia

Question 19

Physical exam findings in aortic dissections:

Answer 19

most commonly normal CV/pulm exam

AI murmur in only 16-20% of patients

abnl. periph. pulses in only ~50%

Question 20

Next steps in patient with suspected aortic dissection:

Answer 20

2 large bore IVs + monitors + type and screen + ECG

Perform CXR

Drop BP to decrease intimal shear forces with a SBP of around 90-100 and a HR of 60-80 by using:

• Nitroprusside
• Esmolol or Labetolol

Surgery if type A
ICU with BP management if type B

Question 21

Diagnostic tests in aortic dissection:

Answer 21

CXR

CT vs TEE vs Aortogram

Question 22

CXR findings for aortic dissection:

Answer 22

Widened Mediastinum
Pleural Effusion
Indinstinct Aortic Knob
Displaced calcified intima (>6mm from outer aortic wall)

Question 23

Mortality of PE:

Answer 23

Mortality is 2-10% if dx/tx

but 30% if undx

Question 24

PE patient presentation:

Answer 24

classic triad of dyspnea, hemoptysis, pleuritic CP

RR > 16

Elevated HR (maybe)

Question 25

What are the Well’s Criteria?

Answer 25

Clinical Signs and Symptoms of DVT +3

PE Is #1 Diagnosis, or Equally Likely +3

Heart Rate > 100 +1.5

Immobilization at least 3 days, or Surgery in the Previous 4 weeks +1.5

Previous, objectively diagnosed PE or DVT +1.5

Hemoptysis +1

Malignancy w/ Treatment within 6 mo, or palliative +1

3-6 pts: 20.5% chance of PE
>6 pts: 67% chance PE

Question 26

ECG findings with a PE

Answer 26

Usually normal
Nonspecific T-wave abnormalities
Sinus Tach
S1 Q3 T3 - only in 6% of patients

Question 27

CXR in PE:

Answer 27

Normal (30%)

ATX in 50%,

elevated hemidiaphragm in 40%

Hampton’s Hump (pleural-based wedge-shaped infiltrate)

Westermark sign (prox. Dilated pulmonary artery w/ abrupt cut-off)

Question 28

Next steps in patient with suspected PE:

Answer 28

Give IVs, O2, and place on monitors

Look for Well’s Criteria

• high pre-test probability, anticoagulate 1st then order study
• heparin

Order CXR
Possible D-Dimer
Order CT

Question 29

Heparin dosing for PE:

Answer 29

80 U/kg IV bolus

18 U/kg/hr IV drip

Question 30

Etiology of spontaneous PTX

Answer 30

often in tall, thin males

10-20% occur w/ exertion, but most result from rupture of subpleural bleb, symptoms vary w/ size+rate of ptx progression

Question 31

Patient presentation with spontaneous PTX:

Answer 31

Acute pleuritic CP in 95%

Dyspnea in 80%

Decreased breath sounds in 85%

Tachypnea >24 in only 5%

Hyperressonance in <30%

Question 32

Next steps in patient with suspected pneumothorax:

Answer 32

If signs of tension ptx: immediate decompression

Non-tension PTX: upright PA CXR

Question 33

Treatment of PTX:

Answer 33

Tube thoracostomy in 2nd intercostal space midclavicular line

Catheter aspiriation (single or sequential)

Observation x 6 hours w/ repeat CXR

Question 34

Signs of Esophageal Rupture:

Answer 34

Chest pain
Dysphagia
History of endoscopy or retching
Dyspnea
Left sided pleural effusion
Pneumomediastinum

Question 35

Dx of Esophageal rupture:

Answer 35

History
CXR
Gastrogaffin swallow