Chest pain and ACS Flashcards
Anginal Equivalents
SOB, Dizziness, Fatigue, Acute Mental Status
The Physical Exam for chest pain
● Nothing all the way to full cardiac arrest
● No findings definitively rule out ACS
● Diaphoresis
● Vitals are vital
○ Hypotension
● Arrhythmias
● New Murmurs
● Pain reproduced by palpation of the chest wall, maybe indicate
musculoskeletal, but does not reliably rule out ACS.
What is your first steps with chest pain in the ED?
● ECG within 10 minutes
● CXR
● Cardiac Monitor
● IV Access
● Oxygen to need <95%
● Further testing determined by suspicion
Dangerous Stuff - Chest pain
Acute Coronary Syndrome
Aortic Dissection
Pulmonary Embolism
Severe Pneumonia
Esophageal Rupture
Tension Pneumothorax
Pleuritic Pain
worse with inspiration, Dyspnea, Hypoxia, Fever
Pulmonary Embolism
○ Increased risk with recent surgery, trauma, prolonged immobility, active
cancer, estrogen from birth control or HRT, PMHx of PE or DVT,
hypercoagulability.
○ Consider a Wells Score or PE Rule Out Criteria
○ Tachypnea, Tachycardia, Hypoxemia
○ D-dimer when negative is useful
○ ECG nonspecific.
○ V/Q scan
○ CT Angiography is test of choice
Aortic Dissection
Classically sudden onset of chest pain with ripping or tearing
radiating to the interscapular area of back
Aortic Dissection workup
○ High risk of misdiagnosis
○ Increased risk with males, poorly controlled HTN, Drug
Abuse (Cocaine, Amphetamines), bicuspid aortic valve,
aortic valve repair, connective tissue disease, pregnancy
○ Pain above and below the diaphragm
○ “Feeling of impending doom”
○ Chest pain with focal neurologic deficit
○ CXR and ECG helpful
○ CT Aortogram is test of choice
Pneumonia pain
Sharp, Pleuritic Pain (worse with inspiration), Dyspnea, Hypoxia
Pneumonia workup
○ Fever, Cough, sputum production, ↓ breath sounds, rales
○ History of aspiration
○ History of Chronic Lung Disease (COPD)
○ Elderly patients, Nursing homes, Pregnancy
○ Tachypnea, Tachycardia, low pulse oximetry
○ Be alert to Sepsis
○ Can admit if refractory to outpatient ABx
○ Chest X-ray is usually diagnostic
Boerhaave’s Syndrome
Esophageal Rupture
● Esophageal contents then leak into mediastinum, pleural space
● Classically sudden onset sharp substernal pain after forceful vomiting
Esophageal Rupture ED workup
● CXR with water soluble contrast
■ Pneumothorax, pneumomediastinum, pneumoperitoneum.
● Emergency Endoscopy
● Chest CT
● Antibiotics
● IV Fluids
● Resuscitation
● Surgical consultation as soon as the diagnosis is entertained
Pneumothorax
● Sudden onset, sharp pleuritic chest pain with dyspnea
○ Tall slender males- Spontaneous
○ Younger ages- teens
○ Can also be traumatic
○ Risk- smoker, chronic lung- Asthma, COPD
○ Chest X-ray is typically diagnostic
○ May see Deep Sulcus sign on CXR
Pericarditis
● Sudden onset, sharp pleuritic chest pain with dyspnea
○ Inflammation of the Pericardium
■ Bacteria, Viral, Fungus, Malignancy, Drugs, Rheumatic disease,
Idiopathic
○ Chest Pain radiating to the back and/or left trapezial area
○ Pain worse when lying supine, improved with sitting up and forward
○ Fever, dyspnea, dysphagia (Irritation of the esophagus)
○ Echocardiography is the best test.
Pericarditis workup
● Physical Exam- Pericardial friction rub (Heard best when having the patient
sitting and lean forward. Listen at left sternal border or apex)
○ ECG can show ST changes in I,V5 and V6 and can be difficult to
distinguish from “early repolarization”
○ Pericardial effusion → Cardiac Tamponade
