Chest pain Flashcards
GI causes of acute onset chest pain
Eosophageal spasm
Pancreatitis
Cholecystitis
Coronary spasm may occur secondary to which drug
Cocaine
What infection can cause attacks of severe pain in the lower chest, often on one side. The slightest movement of the rib cage causes a sharp increase of pain,
This is bornholm disease- causes pain in the chest or upper tummy and flu-like symptoms. (usually affects children/young adults!)
There is inflammation of intercostal muscles due to Cocksackie B virus
What are the clinical signs of hypercholesteralaemia and which of this is a normal finding in the elderly?
Signs of hypercholesterolaemia:
cholesterol deposits in small skin lumps
on the tendons of the back of the hand or bony prominences like elbows
(xanthomata),
in creamy spots around the eyes (xanthelasma), or a
creamy
ring around the cornea (arcus). Note that arcus is a normal finding in the
elderly
Signs of systemic atherosclerotic disease
Signs of systemic atherosclerotic vascular disease: weak pulses, peripheral
cyanosis, atrophic skin, ulcers, bruits on auscultation of carotids.
What is the relevance of AFs to ACS
AFs may exacerbate ACS. If there is AF on top of ACS, it will reduce cardiac output and might push the poorly perfused heart into ischaemia
AF may result from previous ischaemic damage and therefore might offer a clue of what is wrong with the patient
Features of aortic dissection
Aortic dissection:
− History of sudden-onset tearing chest pain radiating to the back.
− Absent pulse in one arm.
− Hypertension (in about 50% of cases) or hypotension (in about 25% of cases).
− A difference in blood pressure between arms >20 mmHg (about a third of
cases).
− New-onset aortic regurgitation. This is caused by the new lumen tracking
down to the valve and making it incompetent.
− Pleural effusion, usually on the left. This is due to irritation of the pleura by
the dissecting aorta
T/F pneumothoraces always comes with chest pain?
What type of chest pain does pneumothorax cause
F
History of sudden-onset pleuritic chest pain with breathlessness – but
beware, it may present as painless breathlessness.
What happens to the chest wall, and what happens to the lung in a pneumothorax
How is this different to what happens with a collapsed lung
Normally lack of air in pleural space creates a vacuum that holds the lung to the chest wall.
When air disrupts this, the unopposed recoild of the chest wall will cause it to pop out, whilst at the same time the lungs will shrivel up.
Note this is diff erent from lung collapse, in which a bronchus is obstructed
and the air trapped distally in that segment is gradually absorbed into the
blood.)
What is the management of a patient when the trachea is deviating away from a suspected pneumothorax?
a trachea that deviates away
from a suspected pneumothorax is an emergency requiring urgent insertion of a large-bore cannula in the mid-clavicular line just above the third
rib to allow the air trapped in the pleural space to escape
Signs of a PE
− Signs of hypoxia. Th e patient may appear pale, have cold peripheries, feel
lethargic and/or be drowsy or confused, depending on the degree of hypoxia.
− Right heart strain evidenced by a raised jugular venous pressure (JVP)
Features of booerhaave’s perforation
− History of sudden-onset severe chest pain immediately following an episode of vomiting. Shortness of breath and pleuritic pain may develop shortly afterwards due to subsequent pleurisy and eff usion
− Signs of a pleural effusion after some hours – dullness to percussion, absent
breath sounds, decreased vocal resonance.
− Subcutaneous emphysema is present in a minority of cases.
− Abdominal rigidity, sweating, fever, tachycardia, and hypotension may be
present as the illness progresses but are non-specific
How often should you do ECG in someone presenting with acute chest pain
2 ECGs 30 minutes apart
Or if continuing chest pain, every 10-15 minutes until diagnosis made
If patient admitted, ECGs should be performed daily for 3 days after as changes might take 24hrs+ to develop.
Looking for signs of ischaemia and AF
Signs of ischaemia on ECG
ST elevation, new onset LBBB
Pathological Q waves (old infarct)
What are the advantages and drawbacks of troponin
+ve:
-Highly sensitive and specific for damage to cardiac muscle
Drawback:
-There is a MINIMUM 8 hour delay in increased troponin levels.`
Alternative to troponin and the benefit of using it
. An alternative is CK-MB, an isotype
of the enzyme creatinine kinase, which is released more rapidly following damage but which is less specifi c for cardiac damage. CK-MB levels fall back to
normal within 2–3 days whereas troponin levels remain high for >7 days.
What does it suggest if CK-MB levels are elevated >4 days after an MI
CK-MB levels that are elevated >4 days after an MI suggest that there has been a re-infarction
T/F troponin is specific for ACS
F.
It IS specific for cardiac damage, but not 100% specific for ACS.
What are the other causes of a raised troponin
Other
conditions causing a raised troponin include: coronary artery spasm (e.g. from
cocaine) or aortic dissection causing ischaemia, myopericarditis, severe heart
failure, cardiac trauma from surgery or road traffic accident, and PE.
How does an MI affect cholesterol levels
An MI will result in a decrease in total cholesterol, low-density
lipoprotein (LDL), and high-density lipoprotein (HDL) within about 24 hours
of the infarct, and that levels will not return to normal (for that patient) for
2–3 months post-infarct.
Thus, cholesterol levels should be measured as soon
as possible if they are to guide future therapy.
What will a chest radiograph typically show with a boerhaave’s perforation
If Boerhaave’s perforation of the oesophagus is suspected, a chest radiograph will typically show air around
the heart shadow (pneumomediastinum), a pleural effusion, and/or a pneumothorax
What drug should you not give to somebody who is having an MI
What should you give
Warfarin (it initially causes clotting by initial inhibition of protein C and S)
You should give LMWH heparin
STEMI management medication do you give to STEMI FIRST
300mg loading dose of aspirin then 75mg maintenance.
If it’s less than 12 hrs since onset then straight to cath lab for PCI
If it’s greater than 12 hrs then you do angiography then PCI cath lab
NSTEMI management
300mg loading dose of aspirin then 75mg maintenance.
Give then fondaparinux and LMWH
Complications of ACS
Death Arrhythmia Rupture (of papillary muscle) Tamponade Heart failure
Valve disease Aneurysm Dressler's syndrome Embolism Re-infarction
Patient presents with following
- Raised JVP
- Muffled heart sound
- Low BP
What position relieves it
What ECG change is likely
Pericarditis!
Diffuse saddle shaped ST elevation!
Sitting forward relieves
What scoring system is used for post NSTEMI risk of death
GRACE
What is LVH on ECG
QRS greater than 7 squares. HTN
Respiratory causes of AF
PE, pneumonia
5 causes of pleuritic chest pain
5Ps: PE Pneumothorax Pericarditis Pleurisy Pneumonia
Subphrenic pathology (abscess), rib fractures and costochondritis
