Chest Pain

Question 0

Mnemonic to guide chest pain history

Answer 0

OLDCARTS

Question 1

What is the first thing to check on all chest pain pts?

Answer 1

Triage note, Vitals, and EKG

Question 2

What are the six deadly “can’t miss”chest pain diseases?

Answer 2

PETMAC

PE, Esophageal rupture, Tension Pneumothorax, MI, Aortic dissection, Cardiac Tamponade

Question 3

5 physical exam finding to always look for in Chest pain pts?

Answer 3

Volume status, pitting edema HF
Murmurs (aortic stenosis)
Abdomen and Back for AAA
Calfs for no putting edema (DVT, PE)
Asymmetric pulses/ BP (Aortic Dissection)

Question 4

Workup in every single CP pt

Answer 4

EKG and CXR

Question 5

Chest Pain + Neuro or Motor sxs =

Answer 5

Aortic Dissection

Question 6

Chest Pain + any unrelated complaint =

Answer 6

Aortic Dissection

Question 7

What is Beck’s Triad and what does it indicate?

Answer 7

Muffled heart sounds, JVD, Hypotension

Indicates cardiac Tamponade

Question 8

Chest Pain + Narrow pulse pressure =

Answer 8

Cardiac Tamponade

Question 9

5 risk factors of esophageal rupture

Answer 9

Free air on CXR
Peritonitis on AB exam
Forceful vomiting
Alcoholic
Recent endoscopy

Question 10

4 Aortic dissection risk factors

Answer 10

Ripping/ tearing chest pain
HTN
Pregnancy
Connective tissue disorders

Question 11

3 cardiac Tamponade risk factors

Answer 11

CA
ESRD
Trauma

Question 12

Labs in general MI workup

Answer 12

EKG
CXR
CBC - anemia
Chem 10 
Coags - in case need to anticoagulate
Enzymes - troponin, BNP, CK-MB, CK

Question 13

Meds for possible MI chest pain pts

Answer 13

ASA
NTG
Morphine + Zofran if still pain after NTG

Question 14

When is troponin first detected in blood and how long will it stay elevated?

Answer 14

4-6 hrs

3-5 days

Question 15

When is CK first detected in blood and how long does it stay elevated?

Answer 15

6-8 hrs

1-2 days

Question 16

Dose of ASA in chest pain

Answer 16

325mg chewed, even if on Coumadin, unless full strength taken w/in 24 hrs

Question 17

Dose of NTG in CP pts

Answer 17

0.4mg SL q5min x 3

Question 18

When do you hold NTG in CP pts?

Answer 18

If CP free, systolic <100
If males on Viagra or Levitra w/in 24 hrs, or sialis w/in 72 hrs.
Check EKG for posterior MI

Question 19

General Workup for pleuritic chest pain (possible PE)

Answer 19

EKG
CXR
CBC
Chem10
Coags incase you need to abnticoagulate

Question 20

When do you need CT angio?

Answer 20

If Gestalt says intermediate or High risk

Question 21

If Pleuritic chest pain and low risk for PE what do you do?

Answer 21

PERC

Question 22

What is the PERC?

Answer 22

BREATHS

Blood in sputum (hemoptysis)
Room air sat < 95%
Estrogen or OCP use
Age > 50
Thrombosis in past (PE or DVT)
Heart rate > 100
Surgery w/in last 4 weeks

Question 23

CP pt low risk for PE + neg PERC =

Answer 23

No more PE workup needed

Question 24

What is the risk of PE in neg PERC?

Answer 24

1.8% | 2% of pts anticoagulated will be harmed so that's why it's ok to stop workup If PERC neg

Question 25

If PERC positive in low risk PE pts what do you do?

Answer 25

Get D-dimer

Question 26

If PERC positive and D-Dimer negative what do you do?

Answer 26

Stop PE workup

Question 27

What is The sensitivity and specificity of D-dimer in PE workup?

Answer 27

``` Se = 95% Sp= 40% ```

Question 28

What is the treatment for small submissive (normal vitals) PE?

Answer 28

Lovenox 1mg/kg subQ, or heparin drip, then get cardiac enzymes, BNP, and Echo. If positive or R heart strain then start Thrombolytics

Question 29

What is the treatment of massive (BP<90) PE?

Answer 29

Thrombolytics