Chest pain Flashcards
6 causes of pneumothorax
Spont
chronic lung disease
infection
trauma
carcinoma
connective tissue disorder
What is a primary vs secondary pneumothorax?
Secondary is due to:
- underlying lung disease
- smoker over 50y
What imaging would you do in pneumothorax? How do you measure how big it is?
- none in tension
- otherwise EXPIRATORY CXR
- size of PT is measured at level of hilum
What could be mistaken for a pneumothorax on a cxr?
Large emphysematous bulla
How do you manage a primary pneumothorax?
If not SOB and/or not >2cm on xray- discharge and review in 2-4w.
If SOB and/or >2cm on xray- aspirate, if unsuccessful then chest drain.
Then discharge and review in 2-4w
How long does a chest drain stay in for
24h after re-expansion and bubbling has stopped
How do you manage a secondary pneumothorax?
If sob or >2cm- chest drain
If not SOB and is 1-2cm- aspirate (chest drain if unsuccessful, admit for 24hr of O2 and obs if successful)
If not SOB and <1cm- admit for O2 and 24hr observation
What additional symptoms do you get in a tension pneumothorax?
Tachycardia
Hypotensive
Distended neck veins
How do you manage a tension pneumothorax
Large bore (14-16G) needle and syringe partially filled with 0.9% saline. 5th IC space, anterior axillary line. Remove plunger until a chest drain is inserted.
Sudden tearing chest pain radiating to back?
Thoracic aortic dissection
Which part of the aorta splits in a dissection?
Tunica media
How can thoracic aortic dissection present other than chest pain?
Syncope
What signs might you get in thoracic aortic dissection?
Hemiplegia (carotid)
Unequal arm pulses and BP
Acute limb ischaemia
Paraplegia (anterior spinal artery)
Anuria (renal artery which is from abdominal aorta at L1-2)
What happens if a thoracic aortic dissection moves proximally?
Can get aortic valve incompetence, inferior MI, cardiac arrest
70% thoracic aortic dissections involve the _____ aorta, this is called Type ___
Ascending
A
What is a type B thoracic aortic dissection? How common is it?
Doesn’t involve the ascending aorta
30%
What should you consider in thoracic aortic dissection Type A (ascending aorta involvement)?
surgery
How would you manage a thoracic aortic dissection?
Crossmatch 10U blood
ECG and CXR
CT and/or TO echo
To ICU
IV beta blockers e.g. labetalol/esmolol (v short acting) to reduce LV pressure. Or CCB if contraindicated.
Morphine
Urgent cardiothoracic advice
What might the CXR show in thoracic aortic dissection?
Widened mediastinum
acute operative mortality rate in thoracic aortic dissection?
<25%
ACS can be which 3 things?
Unstable angina, STEMI, NSTEMI
What signs might you hear on examination in ACS?
3rd/4th HS/quiet 1st HS
Pan systolic murmur
Pericardial rub
Basal crackles (pul oedema)
Hypotension and narrow pulse pressure (<40 difference)
Raised JVP
Tachycardia
Pallor, sweaty
What do you need to assess in the history of ACS?
Risk factors including:
cocaine
connective tissue disease
Rheumatic fever
HTN
smoking
High cholesterol
diabetes
VTE risk
(BUT NB these are the risk factors for atherosclerosis, and women are more likely to have vasospastic disease)
Investigations in ACS
12 lead ECG (+cardiac monitor)
Troponin
CXR if it won’t delay Rx
FBC, UandEs, glucose, lipids, cardiac enzymes, ABG
What could you see on ECG in ACS?
ST elevation
New LBBB
St depression and tall R waves in V1-3
Initial management ACS (basic categories)
MONA
Morphine, O2, Nitrate, Aspirin
How much morphine do you give for ACS?
5-10mg IV (and metaclopromide 10mg IV)
Considerations for giving O2 in ACS
if sats are <94%. NB COPD- give 24-28% in venturi and get an ABG
How do you give the nitrate in ACS?
up to 3 GTN sprays (unless HR <50 or systolic BP <90)
Aspirin dose in ACS
300mg PO
If ACS is found to be a STEMI, what is the further management?
Reperfusion:
If within 12hrs symptom onset and within 120 mins first medical contact (almost all cases)- primary PCI
OR
If within 12hr symptom onset but can’t do PCI then THROMBOLYSIS- alteplase/streptokinase/tenecteplase and transfer to PCI centre
OR
If more than 12hrs since onset or didn’t get reperfused, ANTICOAGULATE give fondaparinux or enoxaparin/unfractioned heparin
ALSO GIVE A BETA BLOCKER TO BE CONTINUED INDEFINITELY
Contraindications to thrombolysis?
Internal bleeding
Recent haemorrhagic stroke/intracranial haemorrhage
Prolonged/traumatic CPR
Heavy vaginal bleeding/<18w postnatal/pregnant
Acute pancreatitis
Active lung disease with cavitation
Cerebral malignancy
Severe HTN (>200/120)
Susp aortic dissection
Prev allergy
Severe liver disease
Oesophageal varices
AV malformation
Recent major trauma or surgery (<2w)
<24hr liver biopsy/LP
What is a risk of thrombolysis?
1/200 pts have a stroke
Can you thrombolyse without ST elevation
No
What do you give as well as PCI/thrombolysis/anticoagulation in STEMI?
beta blocker to continue indefinitely
e.g. bisoprolol 2.5mg PO OD
NB asthma/copd, heart block, HF and cardiogenic shock are contraindications.
The management of NSTEMI/unstable angina is split into which two options?
Low risk and high risk
What constitutes low risk NSTEMI/unstable angina?
No recurrence of pain, no HF signs, normal ECG, negative troponin
How do you manage a low risk NSTEMI/unstable angina?
Discharge
Outpatient investigations e.g. stress test
What constitutes a high risk NSTEMI/unstable angina?
Raised troponin
ECG changes
High GRACE score
Diabetes
CKD
Low LVEF
What score can be done in ACS and what is it for?
GRACE score
Probability of death from admission to 6m (may result in more aggressive management)
Treatment for high risk NSTEMI/unstable angina?
Following MONA….
- Fondaparinux (or LMWH)
- Ticagrelor (or clopidogrel if lower risk or prasugrel if PCI)
- IV nitrate if indicated
- beta blocker
- Cardiology review for angiography
Fondaparinux dose in NSTEMI/unstable angina?
2.5mg OD SC
Ticagrelor dose NSTEMI/unstable angina?
180mg PO
beta blocker dose NSTEMI/unstable angina?
2.5mg OD PO
What time frames are needed for the cardiology review depending on urgency/risk?
Urgent (e.g. ST changes/ arrythmias)- <120m
Early (if GRACE >140 or high risk) <24hr
Low risk- within 72hrs
What are the ACS discharge drugs?
Dual antiplatelet therapy- aspirin and clopidogrel for 12m, then just aspirin.
Beta blocker
ACEi
Statin
+ LIFESTYLE ADVICE
ST elevation in leads 1, V5 and V6 = what type of MI (location and artery)
Lateral
Lateral circumflex
ST elevation in leads II, III and aVF is what type of MI (location and artery)
Inferior
RCA
St elevation in leads V1-V4 is what type of MI (location and artery)
Anterior/septal
LAD
When would you check right sided leads
If you suspect an inferior MI
ST elevation in V4R (Right sided lead) indicates what?
High sens and spec for RV MI
When would you check posterior leads?
When there are prominent R waves and ST depressions in V1-V3. Any degree of ST elevation in posterior leads is significant
Prominent R waves and ST depression in V1-V3 might indicate what?
Posterior MI- check post leads
Do people need a repeat CXR in the management of pneumothorax?
Yes, after aspiration to see if worked, and to check position of chest drain
What amount of ST elevation = ST elevation?
2mm in consecutive chest leads
1mm in consecutive limb leads
