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4Q EM Surg test 2 > Evaluation of Chest Pain > Flashcards

Evaluation of Chest Pain Flashcards

1
Q

What angina symptom do older ppl. often present with?

A

dyspnea

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2
Q

who presents w/atypical chest pain?

A

women, diabetics & elderly

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3
Q

Chest pain: symptoms of 3 other life threatening causes

A

PE: pleuritic, a/w SOB, hemoptysis, risk factors

Aortic Dissection: ripping or tearing chest pain radiating to back/legs/throat, acute onset, a/w HTN, male, 50-70 years old

Cardiac tamponade: pain worse w/laying down, HYPOTENSION, MUFFLED HEART SOUNDS, JVD, pulsus paradoxus

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4
Q

Chest pain hx (memorize this list of 10)

A 
Onset of pain (gradual or acute)
Quality of pain (tearing, burning, stabbing, squeezing, pleuritic)
Radiation (shoulder, jaw, back)
Site (diffuse, localized)
Course (waxing/waning, constant)
Associated symptoms (SOB, N/V, hemoptysis, etc.)
Risk factors
Previous cardiac evaluation?
Ever had this type of pain before?
Social stressors?
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5
Q

Risk factors for CAD (15)

A 
age
gender (M>F)
race
tobacco use
PVD
HTN
HLD
Cancer
Diabetes
Family history
Obesity/physical inactivity
Stress
Alcohol
Illicit drugs
Recent travel or surgery
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6
Q

Chest pain: physical exam (6 areas and what to examine there)

A 
General: anxiety, diaphoretic, pale, cyanosis, Levine's sign
Neck: JVD, carotid bruits
Cardiac: rate, rhythm, murmurs
Lungs: wheezing, rales, flail chest
Abd: epigastric tenderness
Ext: edema, Homan's sign
Skin: lacerations, bruising, lesions
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7
Q

Initial dx workup of chest pain

A 
CBC, CMP
Cardiac enzymes (Troponin, CK-MB)
D-Dimer
BNP (if signs of CHF)
Cardiac monitoring/telemetry
CXR (PA+lateral)
EKG (absence of ischemic changes-risk of AMI 4% w/hx CAD, 2% w/out hx CAD)
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8
Q

Stable angina characteristics

A
  • oxygen supply/demand mismatch
  • occurs with exercise
  • relieved with rest and/or nitroglycerine
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9
Q

Unstable angina characteristics

A
  • more severe, less predictable
  • increasing severity/frequency/duration
  • occurs at rest
  • not relieved with rest and/or nitroglycerin
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10
Q

NSTEMI characterized by

A

non ST elevation MI

  • NON-OCCLUSIVE thrombus
  • ischemia with elevated cardiac enzymes
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11
Q

STEMI characterized by

A

ST elevation MI

  • OCCLUSIVE thrombus
  • transmural infarction
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12
Q

New LBBB are considered

A

MI until proven otherwise

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13
Q

Acute Coronary syndrome hx: Onset

A

gradual & worsens w/exertion, stress

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14
Q

Acute Coronary syndrome hx: time:

A

ANGINA/ISCHEMIA: <10 min, relieved w/rest

INFARCTION: prolonged & more sever, increasing frequency or constant

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15
Q

Acute Coronary syndrome: quality

A

discomfort (pressure, heaviness, tightness, fullness, squeezing)

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16
Q

Acute Coronary syndrome: location

A

substernal or left side chest with radiation to arm, neck, jaw, shoulder, back

NOT related to position or respiration

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17
Q

Most common signs/sxs of ischemic heart dz (8)

A
  • chest pain, pressure, heaviness, tightness, squeezing
  • N/V
  • diaphoresis
  • dyspnea
  • palpitations, bradycardia, tachycardia, irregular
  • syncope, dizziness
  • fatigue
  • fluid overload
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18
Q

What is the best test to identify acute myocardial infarction in ED?

A

12 lead ECG

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19
Q

12-lead ECG: use, goal

A

single best test to ID AMI in ED

goal: w/in 10 mins of presentation
- still low sensitivity (STEMI, NSTEMI, LBBB, paced rhythms)
- Useful in cardiac risk stratification (normal or nonspecific: 1-5% chance MMI, new ischemia increases the risk to 73%)

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20
Q

Troponins: pros, cons

A 
more specific than CK-MB
False positives w/:
-sepsis
-renal failure
-PE (poor prognosis indicator)
-subarachnoid hemorrhage
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21
Q 
Creatine kinase (total & MB)
onset, peak, duration
A

Onset: 3-12 hrs
Peak: 18-24 hrs
Duration: 36-48 hrs

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22
Q

Troponins: onset, peak, duration

A

Onset: 3-12 hrs
Peak: 18-24 hrs
Duration: up to 10 days

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23
Q

Myoglobin: onset, peak, duration

A

Onset: 1-4 hrs
Peak: 6-7 hrs
Duration: 24 hrs

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24
Q

Lactate Dehydrogenase: onset, peak, duration

A

Onset: 6-12 hrs

peak: 24-48 hrs
duration: 6-8 days

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25
Q

ACS lab studies (other than ECG & enzymes)

A

CBC, CMP

CWR: cardiomegaly, pulmonary edema

Echocardiography: LV wall thickness/LV enlargement, regional wall motion, valve function/dz, ejection fraction

Nuclear imaging: myocardial perfusion, localizes & quantifies myocardial damage (more expensive)

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26
Q

ACS treatment

A 
IV access
cardiac monitoring
MONA
Morphine
Oxygen
Nitroglycerin (SL, paste, drip)
ASA 325 mg PO
  • beta blocker (but NOT if pt is bradycardic)
  • unfractionated heparin if indicated
    others: ACE-I, CCB, clopidogrel
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27
Q

ACS-reperfusion

A

PCI, mechanical or pharmacologic:

  • coronary angioplasty w/ or w/out stents; atherectomy
  • fibrinolytic therapy: streptokinase, tPA, reteplase, tenectoplase
  • antiplatelet therapy:glycoprotein IIb/IIA inhibitor (integrelin)

CABG (U) in ppl who can’t be stented

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28
Q

Coronary Artery Bypass Graft (CABG) description

A

surgical grafting of native blood vessels to bypass obstructed coronaries

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29
Q

CABG: where is it desirable, what is used

A

desirable for sites of critical flow (LAD)

Saphenous vein graft: superfluous vein from the leg, 50% patent after 10 years

Internal mammary artery graft:
superfluous branch of subclavian artery, remains patent more often than vein
90% patent after 10 years

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30
Q

Aortic Dissection: definition & presentation

A

severe, acute onset of tearing, sharp or ripping pain radiating to BACK, arms & throat

presentation: UNEQUAL PULSES/BP IN EXTREMITIES, aortic insufficiency murmur
sick appearing: shock, acute HF, CVA/neurologic abnormalities

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31
Q

Aortic dissection risk factors (6)

A
  • HTN
  • s syndrome or connective tissue d/s
  • Biscupid aortic valve
  • Cocaine use
  • Prenancy
  • Family history
32
Q

Aortic Dissection Studies (4)

A

EKG: 15-30% ischemia or non-specific ST/T changes
CXR: 90% have abnormality
CT: CT angiography most widely available & enables prompt dx
TEE: aortic root

33
Q

Aortic Dissection Treatment

A
  • BP & HR control (nitroprusside, beta blockers)
  • Emergent CT surgery consultation
  • Reduce shearing forces & intensity of pulsatile HR
34
Q

Pulmonary Embolism: description & presentation

A

acute onset chest pain OR painless dyspnea

Presentation: tachypnea, tachycardia, hypoxia, hemoptysis, SOB, fever, syncope, unilateral extremity edema suggestive of DVT

35
Q

Risk factors for Pulmonary Embolism

A

Virchow’s triad:
Endothelial damage
Hypercoagulability
Stasis

prolonged immobilization/surgery, pregnancy, cancer
FH of hypercoagulable states

36
Q

Well’s Criteria

A 
suspected DVT=3
PE is #1 dx=3
HR>100=1.5
immobilized>3d 
or surgery<4 w/negative D-dimer, 2% chance of PE
37
Q

Pulmonary Embolism: gold standard for dx

A

Pulmonary angiography

38
Q

Pulmonary Embolism-Labs/Studies & expected results (7)

A

Labs: D-dimer
EKG: sinus tach, S1 Q3 T3 pattern
CXR: (U) normal, classic findings of Hampton’s hump & Westermark’s sign are rare
Gold Standard for dx: pulmonary angiography
Spiral CT w/IV contrast (CTA chest)
V/Q perfusion scan
LE Doppler U/S: used to evaluate for DVT

39
Q

Pulmonary embolism-treatment

A 
anticoagulation
-unfractionated heparin vs. low molecular weight heparin
-warfarin
-fondaparinux
?thrombolytics or embolectomy
?hypercoaguable work-up
40
Q

Pneumothorax presentation & physical exam

A

acute onset of severe sharp pleuritic chest pain, dyspnea

Phys Exam: respiratory distress, hypoxia, tracheal deviation, decreased or absent BS on affected side, hyperresonance to percussion

41
Q

Pneumothorax ABG results

A

high Aa gradient

hypoxemia

42
Q

Pneumothorax: CXR

A

may need lateral decubitus view to see air in pleural space

-tracheal deviation if under tension

43
Q

Pneumothorax tx

A

high flow O2
+/- needle decompression
chest tube
serial CXRs

44
Q

pericarditis presentation

A

constant, sub-sternal, pleuritic pain that
radiates to shoulder or back, worse with lying flat or deep inspiration
-described as “sharp” or stabbing
-relieved with leaning forward

45
Q

Pericarditis ROS

A

+ fever, cough, dyspnea, abdominal pain or dysphagia

46
Q

Pericarditis PE

A

+/- pericardial friction rub

47
Q

Pericarditis causes

A

auto-immune, TB, neoplasm, purulent pericarditis

48
Q

Pericarditis labs/studies & expected findings(3)

A

Labs: leukocytosis, ↑ESR, ↑troponin with NO elevation of CK
ECG: diffuse ST elevation, depression PR segment
CXR/Echo: pericardial fluid

49
Q

Pericarditis Treatment

A

pain medication
anti-inflammatories, ASA, colchicine

+/-cardiac window/ pericardiocentesis
+/-pericardial biopsy (cytology, gram stain with culture, TB PCR)
+/- corticosteroids

50
Q

Pericardial tamponade

A

fluid accumulation that leads to hemodynamic instability

51
Q

Pericardial tamponade causes (6)

A

trauma, aortic dissection, pericarditis, malignancy, recent MI, TB

52
Q

Pericardial Tamponade Presentation

A

Beck’s triad (low arterial blood pressure, distended neck veins, distant muffled heart sounds)
Pulsus paradoxus

53
Q

Pericardial Tamponade-labs/studies

A

ECHO or CT MOST HELPFUL
CXR: enlarged cardiac silhouette
EKG: electrical alternans or low voltage QRS

54
Q

Myocarditis definition

A

inflammation of heart muscle & frequently accompanied by pericarditis

55
Q

Myocarditis presentation

A
  • fever, tachycardia out of proportion with respect to temperature elevation, abnormal heart beat
  • myalgia, HA, fever, rigors
  • can progress to heart failure
56
Q

Myocarditis risk factors

A

M>F, 4th decade, children

57
Q

Myocarditis causes

A

viral (M) common: Coxsackie, Influenza, Parainfluenza, EBV, adenovirus, Hep B & C

bacterial: C. diptheriae, N. meningitides, M pneumonia, B-hemolytic strep

systemic inflammatory dzs: collagen-vascular dz, sarcoidosis, thyrotoxicosis

radiation

hypersensitivity reactions

58
Q

Myocarditis: labs/studies (3)

A

Labs: leukocytosis, elevated cardiac enzymes, ESR/CPR

EKG: non-specific ST/T wave changes, ST elevation (if pericarditis), AV block, prolonged QT

echo to evaluate systolic function

59
Q

Myocarditis tx

A

supportive
+/- antibiotics (depending on cause)
+/- immunosuppressant therapy

60
Q

Mediastinitis presentation

A
  • chest or abdominal pain, cough, hoarseness, dysphagia, history of forceful emesis
  • ill-appearing, shock, fever

HAMMAN’S CRUNCH: crackling sound heart over mediastinum in patients with mediastinal emphysema

61
Q

Mediastinitis: mortality risk?

A

HIGH

62
Q

Mediastinits causes (3)

A

odontogenic infections
esophageal perforation
iatrogenic complications of cardiac surgery, GI or airway procedures

63
Q

Mediastinitis: labs/studies

A

leukocytosis, blood cultures reveal a bacterial source

CXR: mediastinal or free peritoneal air, pleural effusion

CT: extra-esophageal air, mediastinal widening (confirmed with PO contrast), abscess

64
Q

Mediastinitis treatment

A

broad spectrum antibiotics

CT surgery for debridement & repair

65
Q

Pneumonia presentation

A

fever, cough, hypoxia
pleuritic CP
tachycardia, tachypnea

66
Q

Pneumonia physical exam findings

A

rales on affected lobe

decreased breath sounds

67
Q

Pneumonia-labs/studies/findings

A

labs: leukocytosis/leukopenia [leukopenia if infection is pretty advanced]

CXR: consolidation/inflitrate

68
Q

Esophagitis presentation

A

(U) secondary to GERD
cannot be reliably discriminated from myocardial ischemia by history & exam alone

presentation: burning/gnawing chest pain in lower half of chest

69
Q

Esophagitis tx

A
  • GI cocktail (viscous lidocaine, Maalox, donnatol)

- H2 blocker, PPI

70
Q

Esophageal Spasm: presentation & presentation

A

sudden onset of dull, tight or gripping substernal chest pain
(U) precipitated by hot/cold liquids or large food bolus

tx: sublingual nitroglycerin

71
Q

Pleuritis: define, presentation, a/w

A

inflammation of pleura
“dx of exclusion”

presentation: sharp in nature, reproducible, worse w/inspiration “pleuritic”

a/w: PE, pericarditis, pneumonia

72
Q

Costochondritis: definition

A

inflammation of costal cartilages and/or sternal articulations

73
Q

Constochondritis: presentation

A 
chest pain (sharp or dull), ↑with deep inspiration and palpation
do CXR to rule out other causes
74
Q

Costochondritis: treatment

A

anti-inflammatories

75
Q

Herpetic Neuralgia: def & presentation

A

Herpes zoster (shingles)
presentation:
-clusters of vesicles & papules grouped on an erythematous base, vesicles initially clear then cloudy/purulent
-unilateral along dermatome without crossing midline
-shooting, sharp pain. Hyperesthesia with light palpation

4Q EM Surg test 2 (4 decks)

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