Emergency Medicine - Chest Pain Flashcards
unstable angina
new in onset, occurs at rest or is similar but somewhat “different” than previous episodes
stable angina
transient, episodic chest discomfort, predictable, reproducible
substernal chest discomfort >15mins, dyspnea, diaphoresis, LH, palps, N/V
acute MI –> STEMI or NSTEMI
what is the PE of someone with ACS like?
usually nl, 15-20% pts with MI have S3, 15% with ACS have chest wall TTP
CK-MB
elevate at 3-12 hrs after MI, peak at 18-24hrs, duration 2d
troponins
Tn-I similar to CK-MB (elev 3-12hrs) but duration longer (5-10d)
TN-T less sensitive for myocardial injury but indep marker of CV risk
TX of ACS
OH BATMAN! oxygen, heparin, BB, aspirin, thrombolytic, morphine, anti-platelet agent, nitrates
how do nitrates function
decrease preload and afterload, increase coronary perfusion
indications for fibrinolytics
ST elev >0.1mV in 2+ continuous leads or new LBBB and time to therapy <12hrs (class I), 12-24hrs (class II)
what test is most useful in cocaine-related chest pain?
Tn-I. ECG and CK-MB less sens for MI
tx of cocaine related chest pain
benzos, avoid BB
Sx if Ao dissection involves carotid arteries? spinal arteries? AA/renal arteries/iliacs?
stroke. paraplegia. abdominal/flank pain.
Sx if Ao dissection involves coronary arteries
aortic insufficiency, pericardial effusion/tamponade
Ao dissection + hoarseness
laryngeal nerve compression
Ao dissection + dyspnea/stridor/wheeze
tracheal compression
Ao dissection + dysphagia
esophageal compression
type A dissection. risks?
ascending Ao +/- descending Ao. >50yo with HTN.
type B dissection. risks?
descending Ao only. younger pts with marfans, ehler-danlos, pregnancy
Tx ao dissection. goals?
2 large bore IVs, monitor, ECG, IV nitroprusside + esmolol or labetolol to achieve goal SBP 90-100mmHg, HR 60-80. early CT surgery involvement
CXR findings in Ao dissection (4)?
widened mediastinum, L pleural effusion, indistinct Aortic knob, displaced calcified intima >6mm from outer Aortic wall
P pulmonale on ECG
sign of RA enlargement, peaked P in II >2.5mm height. may see in PE
tx of PE
high pretest probability: heparin 80U/kg IV bolus then 18U/kg/hr IV drip then other study.
Low or intermediate pretest probability: study first then anticoag if need. consider thrombolytics if unstable.
tx of TPx and non-tension pnx
TPx - immediate needle decompression then chest tube; non-tension - upright PA CXR.
tube thoracostomy, catheter asp, obs x6hrs with repeat CXR if stable, minimal/no sx, no sig comorbs
Which abnormal heart sound is most associated with Acute MI?
S3 (15-20%)
What is the best diagnostic test for chest pain in the ED to identify Acute MI?
EKG
Which cardiac biomarker is less sensitive for cardiovascular injury? Which cardiac biomarker has the longest duration?
Troponin-T. Troponin-T.
CK-MB sensitivity for MI at presentation? Sensitivity 6 hours later?
50%. 90%.
How does aspirin help treat Acute MI?
Decreases platelet aggregation by inhibiting thromboxane A2.
How do nitrates help treat Acute MI?
Decreases preload and afterload; dilates coronary arteries.
How do beta blockers help treat Acute MI?
Decrease infarct size, CV complications, decrease mortality.
Indications for fibrinolysis in Acute MI (2)?
ST elevation in two or more contiguous leads or new LBB.
Time to therapy less than 24 hours.
Best diagnostic test for cocaine related chest pain? Treatment? What treatment should be avoided?
Troponin I.
Benzodiazepines.
Beta Blockers.
Most common location for aortic dissection?
Ascending aorta at the ligamentum arteriosum.
Stanford Classification for aortic dissections?
Which type is seen in older patients with HTN? Which type is seen in younger patients with Marfan.
Which type is more deadly without surgery?
A: involves Ascending aorta w/ or w/o descending (80% of dissections) - HTN.
B: descending aorta only - Marfan.
Type A deadlier without
If a patient complains of abrupt and severe tearing or ripping chest pain, you should be most worried about? If this pain is in the back?
Ascending Aortic Dissection.
Descending Aortic Dissection.
Unequal peripheral pulses found in what % of thoracic aortic dissections?
50%
After thoracic aortic dissection is seen on CXR, how do you treat it?
IV fluids (get SBP to 110, Pulse 60-80).
Nitroprusside + esmolol or Labetalol to decrease contractility and shear stress.
Surgical repair.
Most common source of PE?
Rare, but pimpable EKG Finding?
Lower extremity DVT.
A large S wave in lead I, a Q wave in lead III, and an inverted T wave in lead III = S1Q3T3.
Virchow’s triad?
Venous Stasis, hypercoagulability, endothelial cell injury.
Number one risk factor for development of PE?
Previous DVT/PE.
Most common physical findings for PE (3)?
Tachypnea, pleuritic chest pain, dyspnea.
Most common finding on CXR for PE?
What is Hampton’s Hump?
What is Westermark sign?
Atelectasis.
Pleural based wedge shaped infiltrate.
Proximally dilated pulmonary artery with abrupt cut-off.
Treatment if high pretest suspiscion of PE?
Anticoagulate 1st, order V/Q, CT angio, etc.
Heparin 80 U/kg i.v. bolus; 18 U/kg/hr i.v. drip
Treatment if low pretest suspicion of PE?
Order V/Q, CT angio, etc., then anticoagulate if necessary.
Most common physical findings for Spontaneous pneumothorax?
Pleuritic chest pain, decreased breath sounds over affected region, Dyspnea.
Cause of spontaneous pneumothorax in thin adult male smoker?
Rupture of a sub-pleural bleb.
What are the BIG 5 scary causes of Chest Pain.
Acute Coronary Syndrome, Pulmonary Embolism, Thoracic Aortic Dissection, Pneumothorax, Esophageal Rupture.
5 things to start for each chest pain patient?
ABCs; IV, O2, monitor, pOx
