Chest Pain Lecture Flashcards
Where does visceral pain come from?
Heart, blood vessels, esophagus, and visceral pleura
What does visceral pain feel like?
Difficult to describe and localize
* Discomfort
* Heaviness
* Pressure
* Tightness
* Aching
Pain may radiate
Where does somatic pain come from?
Chest wall, from dermis to the parietal pleura
How would someone describe somatic pain?
- Easily described and precisely located
- Sharp
- Stabbing
- Scratchy
- Without radiation
What are red flags that require immediate evaluation for chest pain?
- 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
What is initial management of chest pain?
- 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%
What are life-threatening conditions that should be ruled out with a chief complaint of chest pain?
- ACS
- Aortic dissection
- PE
- Severe PNA
- Tension pneumothorax
- Esophageal rupture
What physical exam components should be included in the exam for chest pain?
- Chest
- CV
- Lungs
- Pulses
If a patient has visceral pain, what conditions should be considered?
- Typical angina
*** Unstable angina - Acute myocardial infarction
- Aortic dissection
- Esophageal rupture**
- Esophageal reflux or spasm
- Mitral valve prolapse
If a patient has pleuritic chest pain, what conditions should be considered?
- **Pulmonary embolism
- Pneumonia
- Spontaneous pneumothorax**
- Pericarditis
- Pleurisy
If a patient has chest wall pain, what conditions should be considered
often reproducible pain
- Costochondritis
- Precordial catch syndrome
- Xiphodynia
- Radicular syndromes
- Intercostal nerve syndromes
- Fibromyalgia
How would a patient having ACS present?
- 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
How would a patient with a PE present?
- Focal chest
- Pleuritic pain
- No radiation
- Tachycardia, tachypnea, hypoxia, may have hemoptysis
How would a patient with aortic dissection present?
- Midline, substernal pain location
- Ripping, tearing
- Intrascapular area of back
- Associated secondary arterial branch occlusion
How would a patient with pneumonia describe their pain?
- Focal chest
- Sharp pleuritic
- No radiation
- Associated with fever, hypoxia, may see signs of sepsis
How would a patient with esophageal rupture present?
- Substernal pain
- Sudden, sharp, after forceful vomiting
- Radiates to back
- Associated symptoms of dyspnea, diaphoresis, may see sepsis
How would a patient with pneumothorax present?
- One side of chest
- Sudden, sharp, lancinating, pleuritic
- Shoulder, back radiation
- Associated signs and symptoms: dyspnea
What is the presentation of a patient with pericarditis
- Substernal
- Sharp, constant, or pleuritic character
- Radiation to back, neck, shoulder
- Associated with fever, pericardial friction rub
What is the presentation of a patient with a perforated peptic ulcer?
- Epigastric
- Severe, sharp pain
- Radiation back, up into chest
- Acute distress, diaphoresis
How should a EKG be used to characterize chest pain?
- 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
In which patients should cardiac enzymes be obtained?
- All patients with suspected ACS
Which cardiac enzyme would you order for suspected ACS?
- 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
If you are suspecting pneumonia, pneumothorax, which diagnostic studies would be ordered?
- Chest X-ray –> non-contrast CT
If you suspect a aortic aneurysm/dissection or PE, what is the best imaging study?
- Chest CTA