Chest Pain Flashcards
Dx tests for acute MI:
Physical Exam
ECG
Cardiac Markers
Pros and cons of the different cardiac markers:
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
Treatment for patient with ACS:
“OH BATMAN Mneumonic:
Oxygen heparin beta-blocker aspirin thrombolytic morphine anti-platelet agent nitrates
Examples of common anti-platelet agents:
Plavix
MOA of Aspirin
Irreversibe antiplatelet agent
Inhibits thomboxane A2 and therefore blocks platelet aggregation
MOA of nitrates:
Decrease preload + afterload through massive vasodilation
Increases coronary perfusion
Role of ß-blocker in ACS
decrease infarct size, CV complications, and mortality
When fibrinolytics are indicated in AMI:
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)
Types of cardiac issues associated with cocaine:
6% of patients w/ cocaine-associated chest pain have an AMI (often atypical chest pain)
20-60% have transient myocardial ischemia
Onset of cardiac symptoms in cocaine use:
Can be delayed hours to days after most recent use
Etiology of cardiac issues with cocaine:
spasm
inc. myocardial O2 demand
clot formation
accelerated atherosclerosis w/ LVH
Diagnosis of cocaine related chest pain:
History
Tn-I useful
ECG is less sens/spec than for MI
CK-MB less sens
Prognosis for cocaine related chest pain:
Favorable short term
Higher 1 year mortality due to associated comorbidities or cont. cocaine use
Treatment for cocaine related chest pain:
Benzos
AVOID ß-blockers (unopposed alpha agonism can result in vasospasm)
What is an aortic dissection?
intimal tear w/ entry of blood into media, dissecting btw. intima and adventitia
Most important risk factors for aortic dissection:
**HTN** Age over 50 Ehler-Dahlos Marfan's Pregnancy Bicuspid aortic valve
Prognosis of type A and B thoracic aortic dissections with or without surgery:
Mortality of A = 75% if untreated, 15-20% if sx
B = 32-36% w/ or w/out surgery
Patient presentation in thoracic aortic dissection:
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
Physical exam findings in aortic dissections:
most commonly normal CV/pulm exam
AI murmur in only 16-20% of patients
abnl. periph. pulses in only ~50%
Next steps in patient with suspected aortic dissection:
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
Diagnostic tests in aortic dissection:
CXR
CT vs TEE vs Aortogram
CXR findings for aortic dissection:
Widened Mediastinum
Pleural Effusion
Indinstinct Aortic Knob
Displaced calcified intima (>6mm from outer aortic wall)
Mortality of PE:
Mortality is 2-10% if dx/tx
but 30% if undx
PE patient presentation:
classic triad of dyspnea, hemoptysis, pleuritic CP
RR > 16
Elevated HR (maybe)
What are the Well’s Criteria?
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
ECG findings with a PE
Usually normal
Nonspecific T-wave abnormalities
Sinus Tach
S1 Q3 T3 - only in 6% of patients
CXR in PE:
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)
Next steps in patient with suspected PE:
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
Heparin dosing for PE:
80 U/kg IV bolus
18 U/kg/hr IV drip
Etiology of spontaneous PTX
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
Patient presentation with spontaneous PTX:
Acute pleuritic CP in 95%
Dyspnea in 80%
Decreased breath sounds in 85%
Tachypnea >24 in only 5%
Hyperressonance in <30%
Next steps in patient with suspected pneumothorax:
If signs of tension ptx: immediate decompression
Non-tension PTX: upright PA CXR
Treatment of PTX:
Tube thoracostomy in 2nd intercostal space midclavicular line
Catheter aspiriation (single or sequential)
Observation x 6 hours w/ repeat CXR
Signs of Esophageal Rupture:
Chest pain Dysphagia History of endoscopy or retching Dyspnea Left sided pleural effusion Pneumomediastinum
Dx of Esophageal rupture:
History
CXR
Gastrogaffin swallow
