Chest Pain - Exam 1 Flashcards
What are the two different types of chest pain? What will each feel like? Will it radiate?
visceral: Discomfort, heaviness, pressure, tightness, aching are commonly used descriptors
pain WILL RADIATE
Somatic: Sharp, stabbing, scratchy, without radiation
does not radiate and usually only in 1 area
What organs does visceral type pain usually involve? somatic pain?
heart, blood vessels, esophagus, and visceral pleura
innervates the chest wall, from the dermis to the parietal pleura
What type of pain is difficult to describe and localize? Which one is easily described and precisely located?
visceral: difficult to describe and localize
somatic: easily described and precisely located
What are the 5 chest pain red flags?
- Abnormal vital signs
- concerning EKG findings
- hx of prior CAD
- multiple ASCVD risk factors
- Abrupt onset, new or severe chest pain or dyspnea
What vital signs are considered unstable?
RR >24
HR less than 60 or greater than 120
Abnormal BP
O2 less than 90%
What is the initial management for a pt complaining of chest pain?
Placed in a treatment bed quickly
Cardiac monitoring and IV access (2 large bore)
EKG (within 10 minutes)
Measure vital signs, then resuscitate as needed, following the ABCs
Administer supplemental oxygen if O2 saturation at rest is < 95%*
What are the top 6 ddx that can kill you the fastest with a chest pain CC?
ACS
Aortic dissection
PE
Severe PNA
Tension Pneumothorax
Esophageal rupture
If the pt is complaining of pleuritic chest pain, what are the 3 top ddx you should be thinking?
Pulmonary embolism
Pneumonia
Spontaneous pneumothorax
WShat am I?
Acute coronary syndrome
What am I?
pulmonary embolism
Aortic dissection
Pneuomnia
Esophageal rupture
Pneumothorax
pericarditis
perforated peptic ulcer
What is the associated timeframe that an EKG needs to be completed by? Does a normal EKG rule out an ACS event?
EKG within 10 minutes upon presentation to the ED
normal EKG does NOT rule out ACS event
EKG is normal, now what should you do?
repeat in 15-30 minutes if initially normal, consider serial EKGs
compare to previous EKGs
______ is the first line cardiac enzyme used in the ED. When does it elevate?
troponin
4 hours after onset of acute MI
When do troponin levels peak? **What do you need to remember about troponin levels?
Peaks in 24-48 hours, remains elevated or multiple days
If patient has multiple infarctions in a short amount of time, will remain elevated and is NOT a reliable detector of re-infarcts
_____ is used only if troponin isn’t available or if patient has had an MI in the last 2-3 days. When does the level start to normalize?
CK-MB
levels normalize in 48-72 hours
_____ and _____ should be ordered if concerned about PNA or pneumothorax?
CXR
non-contrast CT
______ should be ordered if concerned about aortic aneurysm/dissection or PE
Chest CTA
______ is used to dx aortic dissection, cardiac tamponade, new regurgitant murmur
Echocardiography
_______ can also present as ishemia/chest pain so important to check CBC
severe anemia
What 4 findings would necessitate an hospital admit if found in combo with chest pain?
Positive cardiac enzymes
New concerning EKG changes
Persistent pain
Concerning physical exam findings
If the pt does NOT have ____, ____ and ______ it is UNLIKELY to have ACS
Negative EKG, cardiac enzymes, and chest x-ray = unlikely to have ACS
**What does a HEART score of 0-3 mean?
2.5% chance of Major adverse cardiac event in next 6 weeks
Discharge home
**What does a HEART score of 4-6 mean?
20.3% chance of MACE event
admit for clinical observation
**What does a HEART score of 7-10 mean?
72.7% MACE
need early invasive strategies
What is defined as a hypertensive crisis? How does this measurement need to be defined?
Defined as a SBP >180 mm Hg and/or DBP >120 mm Hg
BP should be assessed in both arms multiple times
What are the two types of hypertensive crisis? What are the differences?
Hypertensive urgency - no evidence of end-organ damage
Hypertensive emergency - evidence of end-organ damage
What organs are effected the most in a hypertensive crisis?
brain, heart, aorta, kidneys, eyes
What are some fundoscopic findings that would indicate end organ damage?
flame hemorrhage, optic disc swelling,
What are some H&P findings that would indicate end organ damage?
Mental status changes, neurologic dysfunction, seizure, acute severe HA
Visual changes, retinopathy, papilledema
Sudden onset chest pain
Dyspnea
Peripheral edema
Oliguria
What is the management for hypertensive urgency? What is the drug of choice? When do they need to follow up with PCP?
need to control BP within 24-48 hours
No hx of HTN: HCTZ
Hx of HTN: reinstitution or intensification of oral antihypertensive therapy
PCP follow up within 48 hours
How much do you need to reduce BP by in the first hour in a hypertensive crisis? If stable, then what do you do
reduce SBP by no more than 25% in the 1st hour
reduce to 160/100 mm Hg over the next 2 to 6 hours
What happens in a hypertensive crisis if the BP is reduced TOO FAST?
watershed cerebral infarction
aka most distal areas do not get blood supply due to sudden drop in BP
What is the ideal BP for an aortic dissection?
Aortic dissections which require rapid reduction to SBP between 100-120 with in 20 minutes
Acute ischemic stroke with CI to tPA BP are not lowered unless is it _____
≥ 185/110
What is the goal BP for Intracerebral hemorrhage?
SBP gole is 130-140 mmHg
**What is the preferred BP agent for BP crisis in pregnancy?
Hydralazine
** What are the 2 preferred BP lowering agents in strokes?
Enalaprilat or Labetalol
**______ is the preferred BP lowering agent in the ED for renal insufficiency?
Fenoldopam
______ is the preferred BP lowering agents in the ED for aortic dissections?
Esmolol
______ is the preferred BP lowering agents in the ED for SAH and ischemic strokes
nicardipine
_____________ is the preferred BP lowering agents in the ED for CHF?
enalaprilat
What is another name for esophageal rupture? Where is it most likely to tear?
Boerhaave Syndrome
distal ⅓ of the esophagus
What is the MC etiology of an esophageal rupture? Almost all (90%) occur along the _______ of the distal esophagus
forceful vomiting/coughing - MC
left posterolateral wall
How will esophageal rupture present? Where does it radiate? What makes it worse?
Sudden onset substernal chest pain following an episode of forceful vomiting
to the neck or abdomen
neck flexion, breathing, and swallowing
What is Hamman’s crunch? What condition is it associated with?
audible crepitus that varies with the heartbeat on auscultation of the precordium, is a rare finding associated with pneumomediastinum
esophageal rupture
When will a CXR be normal in an esophageal rupture? What other imaging is used to dx?
CXR will be normal within the first 1-2 hours
Contrast esophagram or CT with IV contrast chest
pleural effusion caused by esophageal rupture is mc left or right?
LEFT is more common than right
What are the arrows pointing to?
pneumomediastinum
a condition where air leaks into the mediastinum, the space in the chest between the lungs
What is the management for esophageal rupture?
What is cardiac tamponade? What side of the heart?
An accumulation of fluid within the pericardial space that affects the normal filling pressures of the RIGHT heart chambers.
Why is cardiac tamponade an emergency?
due to severe diastolic dysfunction that leads to reduced cardiac ouput, which leads to cardiogenic shock and then death
Development of diastolic dysfunction in cardiac tamponade results in relation to what 3 things?
rate of fluid accumulation
pericardial compliance
intravascular volume (hypovolemia lowers ventricular filling pressure)
What are 7 causes of atraumatic cardiac tamponade?
**What is Beck’s triad of cardiac tamponade?
hypotension (with narrow pulse pressure)
jugular venous distention
distant heart sounds
How will cardiac tamponade present?
dyspnea at rest and exertion
tachycardia
hypotension with narrow pulse pressure
pulsus paradoxus
JVD
distant heart sounds
What is pulsus paradoxus? Where is it palpable?
A drop of SBP by > 10-20 mmHg during inspiration
Often palpable in the radial, brachial, or femoral pulses as a weakening or disappearance of the pulse during inspiration
_____ is the most sensitive and specific dx tool for cardiac tamponade?
TTE
What will the EKG show on a pt with cardiac tamponade?
low voltage QRS
electrical alternans
signs of underlying dz (pericarditis?
What will pericarditis present like on EKG?
diffuse ST segment elevation
What will the CXR show of a pt with cardiac tamponade?
may be normal or show an enlarged cardiac silhouette
What is the management of cardiac tamponade?
