Chest pain (enhanced learning presentations) Flashcards
What happens in aortic dissection?
-Tear occurs in intima of aortic lining
-Blood surges through the tear forming a haematoma which separates the intima from the middle layer (adventitia)
-Leads to aortic valve damage and reduced blood flow through branch vessels leading to ischaemia
What are the two types of aortic dissection?
-Type A = ascending aorta (2/3), high early mortality
–Caused by cardiac tamponade, interrupted coronary artery flow, sudden severe aortic valve incompetence
-Type B = not involving ascending aorta (1/3), 10-20% early mortality
–Death usually due to malperfusion of visceral organs
What are the main risk factors for aortic dissection?
-HTN
-Bicuspid aortic valve
-Marfan’s / Ehler’s Danlos
-Pregnancy
How does an aortic dissection present?
NB may mimic presentation of MI
S - chest or back
O - abrupt
C - sharp, tearing, ripping
R
A - associated with occlusion of smaller arteries eg syncope, angina, paraplegia, limb ischaemia, neuro deficit
T
E
S - maximal at onset
What findings would you expect on examination?
-Aortic regurgitation
-Asymmetry / absence of peripheral pulses
-Hypotension (A) / hypertension (B)
-Critically ill
What investigations would you order for a patient with aortic dissection?
-Bloods - FBC, U+Es, group+cross match, coagulation
-BP in both arms
-ECG (rule out MI)
-CXR (widened mediastinum, pleural effusion)
-CT angio / TOE if haemodynamically unstable
How would you manage an aortic dissection?
-IV access –> 6 units blood
-Analgesia (morphine)
-ICU/HDU/cardiothoracic referral
-Aim for systolic BP 100-120 (labetolol)
-Surgical management always required for type A
Who tends to suffer from spontaneous pneumothoraces?
PRIMARY = often occurs in previously health individuals, particularly young thin men
SECONDARY = often occurs in older patients or those with:
-Pre-existing lung disease (COPD, asthma, CF, fibrosis, carcinoma)
-Marfan’s
-Oesophageal rupture
-Infection - TB, pneumonia, abscess
How do spontaneous pneumothoraces present?
-Unilateral pleuritic chest pain
-Dyspnoea
-Tachypnoea/cardia
-Hyper-resonant, decreased expansion
-Hypoxia
-Deterioration asthma / COPD
-Decreased air entry
What investigations would you order for a pneumothorax?
-HR, BP, SpO2
-ABG
-CXR
What are the management options for spontaneous pneumothoraces?
Primary:
-if <2cm, no SOB –> ? discharge
-if >2cm, SOB –> chest drain
Secondary:
-if >50, >2cm/SOB –> chest drain
-If 1-2cm –> aspiration, if fails –> chest drain
-if <1cm –> O2 and admit for 24h
-if bilateral or lung fails to expand after drain –> surgery
What happens in a tension pneumothorax?
-Air drawn into pleural space and cannot escape
-Mediastinum pushed contra laterally, kinking / compressing great veins –> cardiorespiratory arrest
What signs would you expect to see in a tension pneumothorax?
-Respiratory distress
-Distended neck veins
-Hypotension
-Tracheal deviation (away from affected side
What management should you carry out for a tension pneumothorax?
-Immediate decompression
–Large bore needle in 2nd ICS MCL
–Syringe and saline to allow air to bubble through
–Chest drain immediately after
What can cause pericarditis?
-Viral - coxackie, TB
-Uraemia
-Trauma
-Post-MI –> Dressler’s syndrome
-Connective tissue disease
-Hypothyroidism
-Malignancy
