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Emergency medicine > Chest Pain > Flashcards

Chest Pain Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

Leading cause of sudden death in US

A

AMI

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2
Q

6 life-threatening causes of chest pain

A 
AMI/unstable angina
Aortic dissection
Pulmonary Embolus
Spontaneous pneumothorax
Esophageal rupture (Boerhaave's syndrome)
Pericarditis/pericardial tamponade
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3
Q

Most specific associated symptom to AMI

A

Diaphoresis. Sweat if your pt sweats!!

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4
Q

Classic RFs for CAD

A 
Male
Smoker
Diabetes
HTN
Age>55
Hyperlipidemia
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5
Q

Conditions that cause inflammation that are a RF for CAD

A

Cocaine abuse
Lupus
HIV
Chronic Kidney Disease

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6
Q

AMI signs on EKG

A

ST segment elevation
Q waves
ST segment depression
Inverted T waves

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7
Q

Most common cardiac enzymes measured

A

Myoglobin, troponin, CPK
used to determine if CP admission requires ICU
Negative in unstable angina–take a few hrs after injury to become +
Need to repeated at intervals

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8
Q

Common Radiology tests

A

CXR–MOST USEFUL. standard part of CP eval
ECHO-wall motion abnormalities in ischemia
CT scan–pulmonary embolism, aortic dissection, esophagus rupture
Esophagram–esophageal rupture

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9
Q

Stress tests–useful in? what does it show?

A

useful in selected low-risk ED patients

shows ischemia, motion abnormalities

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10
Q

Therapeutic treatment

A

Nitroglycerin
GI cocktail
NSAIDs

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11
Q

Common Hx of AMI

A

Pressure, tightness sensation in chest or indigestion
Radiation to jaw, shoulder, neck common
Diaphoresis, nausea, dyspnea
Lasts longer than 15-30 min
Pain at rest, or precipitated by exertion

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12
Q

Common PE of AMI

A

Pt appears anxious, restless, uncomfortable
Pallor & diaphoresis common
brady or tachycardia possible
EXAM OFTEN NORMAL

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13
Q

EKG findings for AMI

A

Hyperacute T waves common early<30 min
ST segment elevation=injury
Look for reciprocal ST segment depression
Inverted T waves=completed infarct

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14
Q

Nonischemic causes of ST segment elevation

Old EKGs are helpful to compare for new changes

A 
LVH
early repolarization
Ventricular aneurysm
LBBB
Veentricular paced rhythms
Pericarditis/myocarditis
Hypertrophic cardiomyopathy
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15
Q

Anterior wall EKG lines

A

V1-V4

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16
Q

Inferior wall EKG lines

A

II, III, and aVF

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17
Q

Lateral Wall EKG lines

A

I, aVL, V5 and V6

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18
Q

Posterior wall EKG lines

A

V1 & V2

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19
Q

ST segment depression

A

denote ischemia, possibly unstable angina

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20
Q

Q waves

A

develop after MI and denote transmural infarct

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21
Q

Inferted T waves

A

completed infarct, last EKG change to develop after MI

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22
Q

Inferior Wall MI

A 
Right coronary a. obstructed
may present with epigastric pain
HypoTN secondary to RV infarction-->tx with IVF bolus
Vagal stimulation causes bradycardia
No signs of CHF on CXR
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23
Q

Anterior Wall MI

A 
Left main or LAD a. obstructed
HypoTN and tachycardia due to LV failure
Requires beta agonist therapy
CXR will show CHF findings
higher mortality than inferior wall MI
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24
Q

AMI cardiac enzymes

A

Myoglobin
CPK-MB
Troponin

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25
Q

Treatment for AMI

A 
IV, O2 & monitor
Aspirin
Nitroglycerin SL or IV
Morphine
Beta-blockers
Heparin
ACE inhibitors
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26
Q

ED Discharge Criteria CP Patients

A

No ischemia on EKG
No history of CAD
Pain is atypical of acute coronary syndrome
Initial cardiac troponin negative
Age < 40 or
41<50 and repeat troponin at least 6 hours from symptom onset is negative

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27
Q

Antithrombin agents

A

Unfractionated IV heparin (UFH)–IV

Low molecular weight heparin (LMWH)–SQ

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28
Q

Antiplatelet Agents

A

Aspirin
GPIIB/IIIA inhibitors–Abciximab-used if going for emergent angioplasty (PCI)
Clopidogrel (Plavix)
Ticlodipine (Ticlid)

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29
Q

How to treat bleeding complications for UFH/LMWH

A

protamine sulfate

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30
Q

Thrombolytics

A 
t-PA
Retavase
TNK-tPA
Max benefit if admin in first hr of CP
Must have ST-segment elevation in 2 consecutive leads or new LBBB
Risks--bad if CNS bleed
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31
Q

Percutaneous coronary intervention (PCI)

A

better long term outcomes than fibrinolytic therapy

Door-to-balloon time of 90 min.

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32
Q

Mechanical Complications of AMI

A

Free wall rupture: 1-5 days post MI

Papillary muscle rupture: new holosystolic murmur, mitral regurg and CHF, tx is surgical

33
Q

Aortic dissection definition

A

intimal tear in lining of aorta. HTN is present 90%

34
Q

History of AOrtic Dissection

A

Severe CP, max at onset
Pain radiates to back &/or abdomen. MIGRATING PAIN
TEARING SENSATION

35
Q

Associated neurologic symptoms for aortic dissection

A

CVA, paraplegia, paresis, visual changes, can cause limb ischemia

36
Q

PE of Aortic Dissection

A

Severe pain, HTN, absent/decreased peripheral pulses
murmur in proximal dissections
BP may be unequal in extremities

37
Q

CXR of Aortic Dissection

A

Widening of mediastinum–caused by false lumen created by tear of aorta
Follow abnormal CXR with CT chest or aortic angiogram

38
Q

EKG findings in Aortic Dissection

A

LVH from long standing HTN

Ischemia of coronary a. dissected/occluded

39
Q

Standford A classification of aortic dissection

A

involves ascending aorta only

40
Q

treatment for stanford A classification

A

surgical correction needed

41
Q

Stanford B classification of aortic dissection

A

only involves distal aorta

42
Q

treatment for Stanford B classification

A

usually medical tx adequate

If complications, surgical correction

43
Q

ED Treatment of aortic dissection

A

Pain control: Morphine drip
BP management: Labetalol, Nitroprusside IV drip + Metoprolol
Early surgical consultation for A and some B

44
Q

Pulmonary Embolism History

A

pain pleuritic, lateral, and abrupt

Dyspnea & cough

45
Q

RF for PE

A 
period of immobilization
casting after orthopedic procedure
pregnancy or bc pills
thrombophlebitis, heart disease, smokers
FH or prior PE
46
Q

PE for Pulmonary Embolism

A 
tachypnea and tachycardia
maybe thrombophlebitis
maybe low grade fever
rales and wheezes
massive PE will present with shock
syncope possible
low pulse ox is a clue
47
Q

Labs for PE

A

ABG will show pO2<80

D-Dimer–HIGH sensitivity in PE and DVT

48
Q

CXR for PE

A

atelectasis
Hampton Hump–pulmonary infarction in lower lung
Westmark’s signs–decrease in blood flow in the are of the blood clot

49
Q

EKG findings for PE

A

Nonspecific ST-T wave changes

Unexplained tachycardia!!

50
Q

Gold standard for dx of PE but not widely available

A

Pulmonary angiogram

51
Q

When to consider a doppler venous study to diagnose DVTs?

A

in pregnant patietns as first test

52
Q

When is Ventilation-perfusion lung scan (V/Q scan) useful for PE?

A

if elevated serum creatinine>1.6

53
Q

Current standard of care for diagnosing PE

A

Helical chest CT scan. IV contrast involved–need adequate renal fxn

54
Q

Treatment for PE

A

Anticoagulation: IV heparin & start PO coumadin. (Lovenox injections if pregnant)
Thrombolytics-for hemodynamically unstable pts
Surgery/IR: pulmonary embolectomy, IVC filters

55
Q

Hx for Pneumothorax

A

dyspnea>pain

CP is pleuritic and lateral

56
Q

Possible Causes of PTX

A

chest trauma, spontaneous in tall thin males, iatrogenic

57
Q

PE of PTX

A

Tachypnea and anxiety

decreased breath sounds

58
Q

PE in tension PTX

A

tracheal deviation
hypotension or altered mental status
distended neck veins

59
Q

CXR for PTX

A

absence of lung markings peripherally
fine line shows pleural lining of lung
EXPIRATORY FILMS INCREASE SIZE OF PTX ON CXR

60
Q

Treatment for small PTX

A

conservative tx and resolves gradually

61
Q

Tx for large PTX

A

tube thoracostomy. simple air aspiration is alternative

62
Q

Tx for Tension PTX

A

immediate needle decompression at 2nd ICS/MCL followed by tube thoracostomy

63
Q

Another name for Esophageal Rupture

A

Boerhaave’s

64
Q

Hx for Esophageal rupture

A

acute, severe CP following vomiting
may have ass. abd pain/neck pain
may have dyspnea, dysphagia, and hematemesis

65
Q

PE for esophageal rupture

A

pneumomediastinum heard as HAMMAN’S CRUNCH
subQ emphysemia may be palpable along chest wall/neck
Tachypnea, tachycardia, and shock likely to develop

66
Q

EKG for esophageal rupture

A

nonspecific changes

67
Q

CXR for esophageal rupture

A

pneumomediastinum, subQ emphysema, an dpossibly L pleural effusion

68
Q

Esophagram with gastrograffin for esophageal rupture

A

leaking of opaque media from the esophagus into the chest

69
Q

Tx for esophageal rupture

A 
rapid dx necessary--HIGH 48 HR MORTALITY
Surgical repair ONLY option
chest ube if effusion present
Braod-spectrum ABX for mediastinitis
FLuid resucscitation if shock present
70
Q

Pericarditis pathogenesis

A

inflammation of the lining of the heart

effusion an develop-up to 50cc normal

71
Q

Hx of Pericarditits

A

Pleuritic sharp CP relieved w/ leaning forward and aggravated by lying supine
low grade fever
dyspnea and dysphagia

72
Q

PE for Pericarditis

A

Pericardial friction rub
low grade fever
JVD if large pericardial effusion (tamponade signs, beck’s traid)

73
Q

Beck’s Triad

A

Hypotension, distended neck veins, muffled heart sounds

74
Q

EKG for Pericarditits

A

Diffuse ST segment elevation
PR segment depression
T wave inversion maybe in later disease
Will see CONCAVE St elevation. (vs. the tombstone ST elevation in an MI)

75
Q

CXR in pericarditits

A

limited value unless large effusion

76
Q

Echocardiography in Pericarditits

A

procedure of choice
Fluid in pericardial space detected in front of RV
RV collapse during diastole diagnostic of tamponade

77
Q

Treatment of idiopathic or viral pericarditis

A

NSAIDS for 1-3 weeks outpatient

78
Q

When to admit a pt with pericarditits?

A

If cardiomegally on CXR or if elevated cardiac enzymes

79
Q

Tx for large pericardial effusion

A

peri-cardiocentesis

Emergency medicine (3 decks)

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