Emergency Medicine - Chest Pain

Question 0

unstable angina

Answer 0

new in onset, occurs at rest or is similar but somewhat “different” than previous episodes

Question 1

stable angina

Answer 1

transient, episodic chest discomfort, predictable, reproducible

Question 2

substernal chest discomfort >15mins, dyspnea, diaphoresis, LH, palps, N/V

Answer 2

acute MI –> STEMI or NSTEMI

Question 3

what is the PE of someone with ACS like?

Answer 3

usually nl, 15-20% pts with MI have S3, 15% with ACS have chest wall TTP

Question 4

CK-MB

Answer 4

elevate at 3-12 hrs after MI, peak at 18-24hrs, duration 2d

Question 5

troponins

Answer 5

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

Question 6

TX of ACS

Answer 6

OH BATMAN! oxygen, heparin, BB, aspirin, thrombolytic, morphine, anti-platelet agent, nitrates

Question 7

how do nitrates function

Answer 7

decrease preload and afterload, increase coronary perfusion

Question 8

indications for fibrinolytics

Answer 8

ST elev >0.1mV in 2+ continuous leads or new LBBB and time to therapy <12hrs (class I), 12-24hrs (class II)

Question 9

what test is most useful in cocaine-related chest pain?

Answer 9

Tn-I. ECG and CK-MB less sens for MI

Question 10

tx of cocaine related chest pain

Answer 10

benzos, avoid BB

Question 11

Sx if Ao dissection involves carotid arteries? spinal arteries? AA/renal arteries/iliacs?

Answer 11

stroke. paraplegia. abdominal/flank pain.

Question 12

Sx if Ao dissection involves coronary arteries

Answer 12

aortic insufficiency, pericardial effusion/tamponade

Question 13

Ao dissection + hoarseness

Answer 13

laryngeal nerve compression

Question 14

Ao dissection + dyspnea/stridor/wheeze

Answer 14

tracheal compression

Question 15

Ao dissection + dysphagia

Answer 15

esophageal compression

Question 16

type A dissection. risks?

Answer 16

ascending Ao +/- descending Ao. >50yo with HTN.

Question 17

type B dissection. risks?

Answer 17

descending Ao only. younger pts with marfans, ehler-danlos, pregnancy

Question 18

Tx ao dissection. goals?

Answer 18

2 large bore IVs, monitor, ECG, IV nitroprusside + esmolol or labetolol to achieve goal SBP 90-100mmHg, HR 60-80. early CT surgery involvement

Question 19

CXR findings in Ao dissection (4)?

Answer 19

widened mediastinum, L pleural effusion, indistinct Aortic knob, displaced calcified intima >6mm from outer Aortic wall

Question 20

P pulmonale on ECG

Answer 20

sign of RA enlargement, peaked P in II >2.5mm height. may see in PE

Question 21

tx of PE

Answer 21

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.

Question 22

tx of TPx and non-tension pnx

Answer 22

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

Question 24

Which abnormal heart sound is most associated with Acute MI?

Answer 24

S3 (15-20%)

Question 25

What is the best diagnostic test for chest pain in the ED to identify Acute MI?

Answer 25

EKG

Question 26

Which cardiac biomarker is less sensitive for cardiovascular injury? Which cardiac biomarker has the longest duration?

Answer 26

Troponin-T. Troponin-T.

Question 27

CK-MB sensitivity for MI at presentation? Sensitivity 6 hours later?

Answer 27

50%. 90%.

Question 28

How does aspirin help treat Acute MI?

Answer 28

Decreases platelet aggregation by inhibiting thromboxane A2.

Question 29

How do nitrates help treat Acute MI?

Answer 29

Decreases preload and afterload; dilates coronary arteries.

Question 30

How do beta blockers help treat Acute MI?

Answer 30

Decrease infarct size, CV complications, decrease mortality.

Question 31

Indications for fibrinolysis in Acute MI (2)?

Answer 31

ST elevation in two or more contiguous leads or new LBB. | Time to therapy less than 24 hours.

Question 32

Best diagnostic test for cocaine related chest pain? Treatment? What treatment should be avoided?

Answer 32

Troponin I. Benzodiazepines. Beta Blockers.

Question 33

Most common location for aortic dissection?

Answer 33

Ascending aorta at the ligamentum arteriosum.

Question 34

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?

Answer 34

A: involves Ascending aorta w/ or w/o descending (80% of dissections) - HTN. B: descending aorta only - Marfan. Type A deadlier without

Question 35

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?

Answer 35

Ascending Aortic Dissection. | Descending Aortic Dissection.

Question 36

Unequal peripheral pulses found in what % of thoracic aortic dissections?

Answer 36

50%

Question 37

After thoracic aortic dissection is seen on CXR, how do you treat it?

Answer 37

IV fluids (get SBP to 110, Pulse 60-80). Nitroprusside + esmolol or Labetalol to decrease contractility and shear stress. Surgical repair.

Question 38

Most common source of PE? | Rare, but pimpable EKG Finding?

Answer 38

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.

Question 39

Virchow's triad?

Answer 39

Venous Stasis, hypercoagulability, endothelial cell injury.

Question 40

Number one risk factor for development of PE?

Answer 40

Previous DVT/PE.

Question 41

Most common physical findings for PE (3)?

Answer 41

Tachypnea, pleuritic chest pain, dyspnea.

Question 42

Most common finding on CXR for PE? What is Hampton's Hump? What is Westermark sign?

Answer 42

Atelectasis. Pleural based wedge shaped infiltrate. Proximally dilated pulmonary artery with abrupt cut-off.

Question 43

Treatment if high pretest suspiscion of PE?

Answer 43

Anticoagulate 1st, order V/Q, CT angio, etc. | Heparin 80 U/kg i.v. bolus; 18 U/kg/hr i.v. drip

Question 44

Treatment if low pretest suspicion of PE?

Answer 44

Order V/Q, CT angio, etc., then anticoagulate if necessary.

Question 45

Most common physical findings for Spontaneous pneumothorax?

Answer 45

Pleuritic chest pain, decreased breath sounds over affected region, Dyspnea.

Question 46

Cause of spontaneous pneumothorax in thin adult male smoker?

Answer 46

Rupture of a sub-pleural bleb.

Question 47

What are the BIG 5 scary causes of Chest Pain.

Answer 47

Acute Coronary Syndrome, Pulmonary Embolism, Thoracic Aortic Dissection, Pneumothorax, Esophageal Rupture.

Question 48

5 things to start for each chest pain patient?

Answer 48

ABCs; IV, O2, monitor, pOx