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Emergency Medicine > Chest Pain Lecture > Flashcards

Chest Pain Lecture Flashcards

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1
Q

Where does visceral pain come from?

A

Heart, blood vessels, esophagus, and visceral pleura

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2
Q

What does visceral pain feel like?

A

Difficult to describe and localize
* Discomfort
* Heaviness
* Pressure
* Tightness
* Aching

Pain may radiate

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3
Q

Where does somatic pain come from?

A

Chest wall, from dermis to the parietal pleura

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4
Q

How would someone describe somatic pain?

A
  • Easily described and precisely located
  • Sharp
  • Stabbing
  • Scratchy
  • Without radiation
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5
Q

What are red flags that require immediate evaluation for chest pain?

A
  • Abnormal vital signs
  • Concerning EKG findings
  • Hx prior CAD
  • Multiple ASCVD risk factors: advanced age, HTN, tobacco use, HLD, DM, obesity, family history, ASCVD, sedentary lifestyle
  • Abrupt onset, new, or severe chest pain or dyspnea
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6
Q

What is initial management of chest pain?

A
  • Place in 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%
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7
Q

What are life-threatening conditions that should be ruled out with a chief complaint of chest pain?

A
  • ACS
  • Aortic dissection
  • PE
  • Severe PNA
  • Tension pneumothorax
  • Esophageal rupture
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8
Q

What physical exam components should be included in the exam for chest pain?

A
  • Chest
  • CV
  • Lungs
  • Pulses
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9
Q

If a patient has visceral pain, what conditions should be considered?

A
  • Typical angina
    *** Unstable angina
  • Acute myocardial infarction
  • Aortic dissection
  • Esophageal rupture**
  • Esophageal reflux or spasm
  • Mitral valve prolapse
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10
Q

If a patient has pleuritic chest pain, what conditions should be considered?

A
  • **Pulmonary embolism
  • Pneumonia
  • Spontaneous pneumothorax**
  • Pericarditis
  • Pleurisy
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11
Q

If a patient has chest wall pain, what conditions should be considered

often reproducible pain

A
  • Costochondritis
  • Precordial catch syndrome
  • Xiphodynia
  • Radicular syndromes
  • Intercostal nerve syndromes
  • Fibromyalgia
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12
Q

How would a patient having ACS present?

A
  • Retrosternal, L chest, or epigastric
  • Crushing, tightness, squeezing, pressure
  • Radiates to R or L shoulder, R or L arm/hand, jaw
  • Associated with dyspnea, diaphoresis, nausea
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13
Q

How would a patient with a PE present?

A
  • Focal chest
  • Pleuritic pain
  • No radiation
  • Tachycardia, tachypnea, hypoxia, may have hemoptysis
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14
Q

How would a patient with aortic dissection present?

A
  • Midline, substernal pain location
  • Ripping, tearing
  • Intrascapular area of back
  • Associated secondary arterial branch occlusion
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15
Q

How would a patient with pneumonia describe their pain?

A
  • Focal chest
  • Sharp pleuritic
  • No radiation
  • Associated with fever, hypoxia, may see signs of sepsis
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16
Q

How would a patient with esophageal rupture present?

A
  • Substernal pain
  • Sudden, sharp, after forceful vomiting
  • Radiates to back
  • Associated symptoms of dyspnea, diaphoresis, may see sepsis
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17
Q

How would a patient with pneumothorax present?

A
  • One side of chest
  • Sudden, sharp, lancinating, pleuritic
  • Shoulder, back radiation
  • Associated signs and symptoms: dyspnea
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18
Q

What is the presentation of a patient with pericarditis

A
  • Substernal
  • Sharp, constant, or pleuritic character
  • Radiation to back, neck, shoulder
  • Associated with fever, pericardial friction rub
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19
Q

What is the presentation of a patient with a perforated peptic ulcer?

A
  • Epigastric
  • Severe, sharp pain
  • Radiation back, up into chest
  • Acute distress, diaphoresis
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20
Q

How should a EKG be used to characterize chest pain?

A
  • Cannot exclude ACS or other life-threatening causes
  • Compare to previous EKGs if available
  • Repeat in 15-30 mins if initially normal
  • Repeat any time reoccurs or worsens
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21
Q

In which patients should cardiac enzymes be obtained?

A
  • All patients with suspected ACS
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22
Q

Which cardiac enzyme would you order for suspected ACS?

A
  • Generally troponin, but elevates in 4 hours and peaks in 24-48 hours and remains elevated
  • CK-MB only if troponin unavailable or patient had MI in last few days, normalizes in 48-72 hours
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23
Q

If you are suspecting pneumonia, pneumothorax, which diagnostic studies would be ordered?

A
  • Chest X-ray –> non-contrast CT
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24
Q

If you suspect a aortic aneurysm/dissection or PE, what is the best imaging study?

A
  • Chest CTA
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25
Q

What conditions can an emergent echo be helpful in?

A
  • Aortic dissection
  • Cardiac tamponade
  • New regurgitant murmur
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26
Q

What tests may be helpful other than cxr, ecg, cta, and echo?

A
  • CBC
  • BMP or CMP (electrolytes could cause issues and may need to check liver/kidney function for med)
  • PT/PTT
  • ABG
  • Type and crossmatch
  • Hcg in women of childbearing age
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27
Q

When would you admit a patient with chest pain?

A
  • Positive cardiac enzymes
  • New concerning EKG changes
  • Persistent pain
  • Concerning physical exam findings
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28
Q

If a patient has a negative EKG, cardiac enzymes, and CXR, what should you do?

A
  • Consider other life-threatening causes
  • If everything else rules out and is pain free, okay to discharge
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29
Q

If a patient has a score of 0-3 on the HEART score, what should their disposition be?

A

2.5% MACE over next 6 weeks, discharge home

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30
Q

If a patient has a HEART score of 4-6, what should their disposition be?

A

20.3% MACE over next 6 weeks –> admit for clinical observation

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31
Q

If a patient has a HEART score of 7-10, what should their disposition be?

A
  • 72.7% MACE over next 6 weeks –> early invasive strategies
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32
Q

What is a hypertensive crisis?

A
  • SBP >180 mmHg and/or DBP >120 mmHg in both arms multiple times
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33
Q

What are the 2 types of hypertensive crisis?

A
  • Hypertensive urgency- no evidence of end-organ damage
  • Hypertensive emergency- evidence of end-organ damage (brain, heart, aorta, kidneys, eyes)
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34
Q

What are conditions caused by hypertensive emergency?

A
  • Brain: hypertensive encephalopathy, SAH, ICH, ischemic CVA
  • Heart: acute pulmonary edema, MI, ACS
  • Aorta: aortic dissection
  • Kidney: acute renal failure
  • Eyes: hypertensive retinopathy
  • Multiorgan: preeclampsia, eclampsia, acute perioperative HTN, sympathetic crisis
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35
Q

What are signs of end-organ damage?

A
  • Mental status changes, neurologic dysfunction, seizure, acute severe HA
  • Visual changes, retinopathy, papilledema
  • Sudden onset chest pain
  • Dyspnea
  • Peripheral edema
  • Oliguria
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36
Q

What are labs for hypertensive crisis?

looking for end-organ damage

A
  • BMP: acute elevation of serum creatinine
  • UA: proteinuria, red blood cells, or red cell casts
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37
Q

What are imaging/diagnostics for hypertensive crisis?

A
  • Chest X-ray (pulmonary edema or thoracic aortic dissection)
  • ECG (cardiac ischemia)
  • CT head without contrast (neurologic changes/CVA_
    *CTA chest (chest pain/aortic dissection)
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38
Q

How is hypertensive urgency managed?

A
  • BP control within 24-48 hours
  • If no hx of HTN: HCTZ
  • If hx of HTN: reinstitution or intensification of oral antihypertensive therapy
  • Discharged home with rapid follow-up with PCP (within 48 hours)

hypertensiveurgenz (HCTZ)

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39
Q

How is hypertensive emergency managed?

A
  • Rapid, controlled reduction in BP using IV antihypertensives. Reduce SBP by no more than 25% in first hour (aortic dissections, acute ischemic strokes, intracerebral hemorrhage are exceptions)
  • If stable, reduce to 160/100 mmHg over next 2-6 hours
  • If stability remains, reduce to normal over following 24-48 hour
  • Drug of choice tailored to system showing end-organ damage
  • Admit to CCU or ICU
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40
Q

What can rapid reduction of BP in hypertensive crisis cause?

A

Watershed cerebral infarction

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41
Q

A patient has hypertensive emergency leading to a stroke. What drugs would you consider?

A
  • Ischemic stroke: nicardipine
  • Stroke: labetolol or enalaprilat

ischemia no flow nicardipine
la la stroke (labetolol, enalaprilat)

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42
Q

A patient has a SAH related to hypertensive emergency. What antihypertensive would you give?

A
  • Nicardipine

subno

43
Q

A patient has a aortic dissection due to hypertensive emergency. What antihypertensive would be given?

A

Labetolol or esmolol

the aorta cheated on beta with esmo

44
Q

A patient has renal insufficiency or failure due to hypertensive emergency. What antihypertensive should be used?

A
  • Fenoldopam

old kidneys

45
Q

A patient is experiencing CHF due to hypertensive emergency. What medication should be used?

A
  • Enalaprilat

end HF (enalaprilat)

46
Q

A patient is pregnant with hypertensive emergency. What antihypertensive should be given?

A
  • Hydralazine

amnioticfluid - hydra

47
Q

What should you be aware of when prescribing nicardipine for hypertensive emergency?

A

May precipitate myocardial ischemia

48
Q

Tear or rupture in distal 1/3 of esophagus resulting in pneumomediastinum

A

Esophageal rupture

49
Q

What is the etiology of esophageal rupture?

A
  • Forceful vomiting/coughing (MC)
  • Blunt and penetrating chest trauma
  • Iatrogenic (endoscopy)
  • Foreign body ingestion
  • Caustic substance ingestion
  • Complications of esophageal cancer
50
Q

Where do almost all esophageal ruptures occur?

A
  • Left posterolateral wall of distal esophagus
51
Q

What is the clinical presentation of esophageal rupture?

A
  • Sudden onset substernal chest pain following episode of forceful vomiting
  • Pain may radiate into neck or abdomen
  • Worsened by neck flexion, breathing, and swallowing
52
Q

What are associated signs and symptoms of esophageal rupture?

A
  • Fever, diaphoresis
  • Dyspnea
  • Tachycardia
  • Subcutaneous emphysema (palpable and audible Hamman’s crunch)
  • rapid development of sepsis
53
Q

What imaging can be used to show esophageal rupture?

A
  • CXR: may be normal initially, may show pneumomediastinum, pneumoperitoneum, pneumothorax; pleural effusion
  • Contrast esophagram: water-soluble contrast, extravasation of contrast into mediastinum and pleural space
  • CT with IV contrast chest
54
Q

How is esophageal rupture managed?

A
  • Stabilize air way
  • NPO, IV fluids
  • Broad spectrum IV antibiotics
  • NG or OG tube placement
  • Consult surgery

NG or OG tube prevents saliva and gastric content contamination

55
Q

What broad spectrum antibiotics are used for esophageal rupture?

A
  • First line: ampicillin/sulbactam (Unasyn) or pip/taz (Zosyn)
  • Beta-lactam allergy: clindamycin + ciprofloxacin

one esophagus (unasyn or zosyn)

56
Q

Accumulation of fluid within the pericardial space that affects the normal filling pressures of the right heart chambers

A

Cardiac tamponade

57
Q

What causes death with cardiac tamponade?

A
  • Diastolic dysfunction –> reduced cardiac output –> shock –> death
58
Q

What impacts the rate of development of diastolic dysfunction with cardiac tamponade?

A
  • Rate of fluid accumulation
  • Pericardial compliance
  • Intravascular volume (hypovolemia lowers ventricular filling pressure)
59
Q

What is the clinical presentation of cardiac tamponade?

A
  • Dyspnea at rest and with exertion
  • Tachycardia
  • Hypotension with a narrow pulse pressure, usually due to a drop in SBP
  • Pulsus paradoxus
  • Jugular venous distention
  • Distant heart sounds on auscultation
60
Q

What is pulsus paradoxus?

A
  • Drop of SBP by >10-20 mHg during inspiration
  • Often palpable in radial, brachial, or femoral pulses as weakening or disappearance of pulse during inspiration
61
Q

How is cardiac tamponade diagnosed?

A
  • Transthoracic echo (most sensitive and specific)
  • ECG: low voltage, electrical alternans, signs of underlying disease (ie ST segment elevation in pericarditis
  • CXR: may be normal or show enlarged cardiac silhouette
62
Q

How is cardiac tamponade managed?

A
  • Resuscitation with oxygen, large bore IV fluids to maintain pressure, continuous EKG monitoring, BP monitoring q 5-15 minutes
  • Emergency pericardiocentesis if signs of decompensation
  • Urgent consult to cardiology and cardiothoracic surgery for pericardiocentesis
63
Q

Characteristics of ACS

A
  • Chest pain or discomfort with radiation to arm, neck, or jaw
64
Q

Precipitating factors of ACS

A
  • Exercise
  • Stress
  • a Cold
65
Q

Timing of ACS

A
  • Duration <10 minutes, occasionally up to 10-20 mins
  • Usually improves within 2-5 mins after rest or with nitro
66
Q

Associated symptoms with ACS

A
  • Nausea
  • Vomiting
  • Abdominal bloating
  • Diaphoresis
  • Dyspnea
  • Lightheadedness
  • Dizziness
  • Syncope
  • Anxiety
  • Restlessness
  • Palpitations
67
Q

Pops with atypical presentation of ACS

A
  • Female
  • Elderly
  • Diabetic
68
Q

PE for ACS

A
  • Well appearing to uncomfortable, pale, cyanotic, in respiratory distress

Complications –> abnormal PE
* Cardiac muscle ischemia can lead to heart failure or shock
* Ventricular aneurysm or rupture
* Arrhythmias if conducting tissues affected
* Infarcted endocardium attracts clots –> PE or CVA
* Left wall non-compliance –> S3 (overly dilated LV) or S4 (non-compliant LV)

69
Q

Diagnostics for STEMI

A
  • STEMI: new or presumed new ST elevation of >1 mm in 2 anatomically contiguous leads
  • Exception in V2 and V3 where >2 mm must be seen in men and >.15-1.5 mm in women
  • New LBBB
  • Troponin rise in 2-6 hours with peak at 12-24
  • CBC, BMP, PT/PTT
70
Q

Diagnostics for NSTEMI

A
  • New or presumed new horizontal or down sloping ST depression >.5 mm in two anatomically contiguous leads AND/or T wave inversion >.11 mm in two anatomically contiguous leads with prominent R wave or R/S ratio >1
  • Troponin elevation
  • CBC, BMP, PT/PTT
71
Q

Initial management for all ACS

A
  • Cardiac monitoring
  • IV line (2 large bore)
  • Oxygen if <94%
  • ASA 160-325 chewed, alt clopidogrel for true ASA allergy
  • NTG .4 mg SL or one spray if active chest pain repeat if no effect in 5 mins
  • Morphine if pain not relieved with NTG
  • B-blocker and statin therapy started within 24 hours
  • IV NTG, IV clevidipine, nicardipine, metoprolol, or esmolol if BP elevated despite SL NTG
72
Q

MOA of NTG

A

Reduces left ventricular after load through arterial dilation as well as preload through venous dilation

73
Q

What should you do if chest pain returns or continues and SBP >100 after nitro SL

A

IV NTG at 10 ug/min and increase by 5 ug/min every 3-5 mins until SBP falls by 10% or chest pain is relieved keep SBP above 90

74
Q

CIs to NTG

A
  • Severe aortic stenosis
  • HCM
  • Suspected right ventricular infarct (inferior STEMI with elevation in V1)
  • Hypotension (SBP <90 or >30 mmHg below baseline)
  • Bradycardia or tachycardia
  • PDE5 inhibitor in last 24 hrs
75
Q

Why would you consider B-blocker and statin in ED?

A

Refractory hypertension or ongoing ischemia
Cardioselective preferred: metoprolol or atenolol

76
Q

CI to B blcoker and statin therapy for ACS

A
  • CHF
  • Bradycardia
  • Conduction blocks
  • Hypotension
77
Q

Characteristics of unstable angina

A

One of the following:
* Began in last 2 months
* Increasing frequency, intensity, or duration
* Existing angina occurring at rest

78
Q

Management of unstable angina and NSTEMI

A
  • Initial as above
  • Deterine management strategy (consult cardiology):
  • Early invasive: coronary angiography with PCI vss CABG
  • COnservative: medical therapy only

Dual antiplatelet therapy for all patients: ASA for all, P2Y12 inhibitor (discuss preference with cardiologist): either clopidogrel, ticagrelor, or prasugrel

  • Anticoagulant therapy UFH if invasive approach chosen
  • LMWH if conservative approach
79
Q

STEMI management

A
  • Reperfusion with PCI or fibrinolytic
  • Antiplatelet therapy
  • Anticoagulant therapy
80
Q

Goal of PCI reperfusion

A
  • 90 minutes if at PCI facility
  • 120 mins if non-PCI facility
  • Door to departure time <30 mins if non-PCI facility
81
Q

Indications for fibrinolytics vs PCI for STEMI

A
  • Unable to get to PCI within 120 mins of first medical contact with symptoms that have been present <12 hours
  • Goal door to needle time <30 mins
82
Q

Fibrinolytic agents for STEMI

A

tPA, rPA, and TNK

83
Q

Disposition of STEMI management

A

PCI-go to cath lab from ER
All receiving fibrinolytic therapy must be admitted to ICU ASAP

84
Q

Chest pain Pattern of discomfort, frequency of occurence, and precipitating factors have remained the same for 3 + months

A

Stable angina

85
Q

How long does pain in stable angina usually last?

A

1-15 mins relieved by NTG

86
Q

Tx of stable angina

A

NTG .4 mg SL at onset of pain
Usually improvement within 1-2 mins
If no improvement after 5 mins call 911 repeat dose every 5 mins with max of 3 doses

87
Q

Chest discomfort in absence of precipitating event occurring at rest or waking patient up at night. Often associated with transient ST segment elevation or depression that is reversed after NTG

A

Vasospastic or Prinzmetal angina

88
Q

Treatment of Vasospastic or Prinzmetal angina

A

Nitroglycerin .4 mg SL

89
Q

Intima of aorta tears and blood goes between intima and adventitia

A

aortic dissection

90
Q

90% of all aortic dissections occur where?

A
  • Right lateral wall of proximal ascending aorta
91
Q

Risk factors for aortic dissection

A
  • Male sex
  • Age over 50
  • Poorly controlled hypertension
  • Cocaine or amphetamine use
  • Bicuspid aortic valve or prior aortic valve replacement
  • Certain connective tissue disorders (marfan’s syndrome and ehlers-danlos syndrome)
  • Pregnancy
92
Q

Clinical presentation of aortic dissection

A
  • Lack of classical presentation, typical symptoms less likely in patients >70 (1/3 of all cases)
  • Sudden severe pain in chest MC with stanford type A and back pain with stanford type B often a combo of both
  • Radiation into abdomen in <50% patients
  • Sharp, ripping or tearing, rarely migrating
  • Secondary symptoms d/t arterial branch occlusions: neurologic symptoms, syncope, SOB, limb ischemic pain
93
Q

PE for aortic dissection

A
  • BP hypotensive to normotensive to hypertensive
  • May have unilateral pulse deficit carotid, radial, or femoral arteries; most frequently in young patients and males, less frequently in >70 and females
  • If aortic regurgitation: diastolic murmur
  • Cardiac tamponade
94
Q

Aortic regurgitation presentation with dissection

A

MC in patients <70 yo
Soft, high pitched, early diastolic decrescendo murmur heard best at 3rd intercostal space on left (Erb’s point) on end expiration with patient sitting up and leaning forward

95
Q

How is ADDRS used?

A
  • Review each high risk category and assign score 0-3
  • Score of 0-1 order d-dimer, if d-dimer >500 ng/mL, order CTA
  • Score 2-3 skip d-dimer and order CTA
96
Q

Diagnostics for aortic dissection

A
  • CXR: widening of mediastinum
  • EKG: may be normal, non-specific ST degment or T-wave changes, ischemic changes
  • D-Dimer <500 ng/mL 97% sensitivity that dissection not present, but many conditions can increase dimer levels
  • CT angiogram/aortogram preferred: requires IV contrast
  • TEE: highly sensitive and specific but limited by sedation, experience echocardiographer and cardiology to interpret
97
Q

Management of aortic dissection

A
  • Resuscitate as needed
  • Reduce BP and HR with B blocker: esmolol or labetolol with goal HR 60 bpm and SBP 120-130
  • Pain control: fentanyl
  • Emergent consult with vascular surgery
  • Disposition: if not taken directly to OR per surgeon decision admit to ICU
98
Q

What should you monitor for with beta blocker use in aortic dissection

A

end organ hypoperfusion

b blocker prevents extension of dissection

99
Q

What would be used if BP not controlled with B-blocker

A
  • IV nicardipine, clevidipine, nitroglycerin, or nitroprusside
100
Q

Etiology of pericarditis

A
  • Viral
  • Post-cardiac injury
  • Radiation
  • Drugs/toxin
  • Malignant
  • Idiopathic
101
Q

Clinical presentation of pericarditis

A
  • Sharp, sever, constant pain with substernal location
  • Sudden or gradual onset
  • Radiation to back, neck, or shoulders
  • Worsened by lying flat and by inspiration and relieved by sitting up and leaning forward
  • Associated symptoms: fever, dyspnea due to accentuated pain with inspiration, dysphagia from irritation of esophagus by posterior pericardium
  • Pericardial friction rub
102
Q

Diagnostics for pericarditis

A
  • EKG: diffuse ST segment elevation with PR depression and ST segment depression in aVR, ST elevation d/t inflammation of epimyocardium
  • CXR: differentiate left heart failure from pericardial effusion
  • TTE: normal unless pericardial effusion
  • Labs: make diagnosis and look for complications –> CBC, BMP, ESR, CRP, troponin, BNP
103
Q

Management of pericarditis

A
  • Stable patients with idiopathic or viral pericarditis may be discharged home
  • Physical ativity restriction until all symptoms resolve
  • First line- NSAID: ibuprofen for 7-10 days
  • Colchicine added to NSAID if hx recurrent pericarditis
  • Follow up with PCP or cardiology in 3-5 days
104
Q

Indications for admission of pericarditis (still treat with NSAID)

A
  • Temperature >38 C (100.4)
  • Subacute onset over weeks
  • Immunosuppression
  • History of oral anticoagulant use
  • Associated myocarditis (elevated cardiac biomarkers, symptoms of heart failure)
  • Failure to respond to therapy with NSAIDs after 1 week of therapy
  • Large pericardial effusion (echo-free space >20 mm)
  • Cardiac tamponade
  • Uremic pericarditis (renal failure)
  • Hemodynamic compromise

Emergency Medicine (13 decks)

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