EM: chest pain

Question 1

what are our 6 differentials for chest pain?

Answer 1

“PET MAC”
PE, esophageal rupture, tension pneumo
MI, aortic dissection, cardiac tamponade
…. and many others

Question 2

what is acute coronary syndrome?

Answer 2

Acute plaque rupture and coronary artery occlusion causing myocardial ischemia

Question 3

what are the most predictive signs of ACS?

Answer 3

vomitting, SOB, radiation to arms, diaphoresis

Question 4

ACS; how does a silent MI present? what patient population?

Answer 4

weakness, abdominal pain, jaw pain, or dyspnea without chest pain, most commonly in women, diabetic patients, and elderly patients

Question 5

what is our “classic order set” for chest pain?

Answer 5

IV, EKG, cardiac monitoring, chest x-ray, CBC, BMP/CMP, troponin, +/- lipase

Question 6

what do you do for someone with suspected ACS? (orders, meds)

Answer 6

order- classic chest order

meds: ASA 324mg PO, nitroglycerine every 5 min up to 3 doses (maybe add analgesic - fentanyl, maybe add O2)

Question 7

Dx for ACS: how do you Dx a STEMI/heart alert vs NSTEMI vs something else that needs cardiology consult

Answer 7

Ischemic EKG = STEMI / Heart alert
Elevated troponin = NSTEMI
Concerning history but everything is negative = Cardiology consult

Question 8

what is the HEART score?

Answer 8

a scoring system comparing History, EKG, Age, Risk Factors, and Troponin level.
- tells you the risk of them having a MACE (major adverse cardiac event)

Question 9

txt: STEMI vs NSTEMI

Answer 9

STEMI: percutaneous coronary intervention (PCI) (first choice)
CABG (second choice)
add: thrombolytic therapy (if unable to get to PCI within 90min)
STEMI or NSTEMI: unfractionated heparin then admission

Question 10

pulmonary embolism: what is it? most common cause? classic presentation?

Answer 10

Thrombus of the pulmonary artery or its branches
(Most commonly caused by lower extremity DVTs)
Classically presents as dyspnea, pleuritic chest pain, hemoptysis

Question 11

what to order for PE?

Answer 11

Chest pain workup plus…
PERC negative= nothing
low-medium risk = D-dimer (with Well’s criteria)
high risk= CTA chest
CTA contraindicated= V/Q scan or doppler US of LE

Question 12

what is the PERC score?

Answer 12

scoring system to rule out PE

Question 13

what is the classic EKG finding for a PE? (kinda weeds)

Answer 13

“S1Q3T3” pattern: (the McGinn-White Sign)
large S wave in lead I, a Q wave in lead III and an inverted T wave in lead III together indicate acute right heart strain.

Question 14

txt for a PE?

Answer 14

nonmassive= heparin
low bleeding risk = systemic lysis
high bleed risk = catheter directed lysis or surgical embolectomy

Question 15

what is an aortic dissection? what are the classic S+S?

Answer 15

tear in the innermost layer of the aorta

S+S: Chest pain PLUS- back pain, HTN, new murmur, neuro defects

Question 16

what are the two classification types for aortic dissection?

Answer 16

DeBakey and Stanford
(based on location and percentage dissected )
Stanford: A: proximal
Stanford B: distal

Question 17

what do you order for suspected aortic dissection?

Answer 17

Chest pain workup + CTA of chest

Question 18

what might you see on CTA of aortic dissection?

Answer 18

widening of the mediastinum

Question 19

txt for aortic dissection? (definitive vs what we can do for them in the ER)

Answer 19

Treatment: surgery

-Goals in the ER- initially get HR less than 60bpm, systolic BP 100-120 (give esmolol for HR and nicardipine for BP)

Question 20

what is an esophageal rupture? classic signs? causes?

Answer 20

Full thickness rupture of the distal esophagus

signs: Retrosternal chest pain worse with deep breathing and swallowing
- after forceful vomiting or from iatrogenic perforation during endoscopy

Question 21

what 3 things do you order for suspected esophageal rupture? which is the best?

Answer 21

Chest Xray- may see pneumomediastinum (air around heart)
Chest CT
Contrast esophagram (best test)

Question 22

txt for esophageal rupture: stable vs unstable

Answer 22

Small/Stable: NPO, antibiotics, H2 blockers

Large/Unstable: Surgery

Question 23

what is a pneumothorax? what are the 3 different classifications?

Answer 23

Occurs when free air enters the space between the visceral and parietal pleura
Primary: Without apparent lung disease(Classically tall thin men)
Secondary: With underlying lung disease(COPD most common)
Traumatic: Including iatrogenic

Question 24

what is a tension pneumothorax? what are the effects of it?

Answer 24

intrathoracic pressure increases to greater than 15-20mmHg — shifts heart and great vessels
-venous return, diastolic filling and CO are decreased

Question 25

how is a tension pneumo Dx?

Answer 25

clinically (need to know what this is before imaging) - too dangerous!

Question 26

US: normal vs abnormal signs to Dx pneumothorax

Answer 26

(seashore- normal, barcode or stratosphere sign- abnormal)- want to see lung sliding in normal lungs

Question 27

what can you order to Dx a suspected pneumothorax?

Answer 27

chest Xray, CT, US

Question 28

txt for pneumothorax: stable vs unstable vs tension pneumo

Answer 28

stable- give O2 for 6hrs and observe, redo the CXR
unstable- chest tube
tension- needle decompression prior to any imaging, then chest tube

Question 29

cardiac tamponade: what is it? classic signs?

Answer 29

Pericardial effusion that puts enough pressure on the heart to limit ventricular filling
Beck’s Triad: muffled heart sounds, increased jugular venous pressure, hypotension

Question 30

what do you order to Dx suspected cardiac tamponade?

Answer 30

bedside US (see effusion and compressed ventricles)

Question 31

txt for cardiac tamponade?

Answer 31

pericardiocentesis, then surgery

Question 32

what signs on an EKG may help confirm cardiac tamponade? (Weeds)

Answer 32

tachycardia and “low voltage” < 1large box in leads I, II, III (box is bigger than the actual wave)
OR QRS complexes which are tall then short (every other complex)