Chest pain Flashcards by Alice Hanton

6 causes of pneumothorax

Spont

chronic lung disease

infection

trauma

carcinoma

connective tissue disorder

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What is a primary vs secondary pneumothorax?

Secondary is due to:

underlying lung disease
smoker over 50y

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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

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What could be mistaken for a pneumothorax on a cxr?

Large emphysematous bulla

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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

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How long does a chest drain stay in for

24h after re-expansion and bubbling has stopped

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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

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What additional symptoms do you get in a tension pneumothorax?

Tachycardia

Hypotensive

Distended neck veins

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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.

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Sudden tearing chest pain radiating to back?

Thoracic aortic dissection

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Which part of the aorta splits in a dissection?

Tunica media

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How can thoracic aortic dissection present other than chest pain?

Syncope

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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)

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What happens if a thoracic aortic dissection moves proximally?

Can get aortic valve incompetence, inferior MI, cardiac arrest

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70% thoracic aortic dissections involve the _____ aorta, this is called Type ___

Ascending

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What is a type B thoracic aortic dissection? How common is it?

Doesn’t involve the ascending aorta

30%

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What should you consider in thoracic aortic dissection Type A (ascending aorta involvement)?

surgery

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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

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What might the CXR show in thoracic aortic dissection?

Widened mediastinum

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acute operative mortality rate in thoracic aortic dissection?

<25%

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ACS can be which 3 things?

Unstable angina, STEMI, NSTEMI

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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

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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

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.... 1. Fondaparinux (or LMWH) 2. Ticagrelor (or clopidogrel if lower risk or prasugrel if PCI) 3. IV nitrate if indicated 4. beta blocker 5. 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