Evaluation of the Adult with CP in the ED Flashcards
1
Q
2nd most common complaint in ED
A
chest pain
2
Q
percent of adults with chest pain
A
~5%
3
Q
Exclude life-threatening causes
A
- Acute Coronary Syndrome
- Pulmonary Embolism
- Aortic Dissection
- Esophageal Rupture
- Tension Pneumothorax
- Pericardial Tamponade
4
Q
Acute coronary syndrome
A
- Unstable Angina
- ST segment elevation MI
- Non-ST segment elevation MI
5
Q
Angina
A
- sensations in chest of squeezing, heaviness, pressure, weight, vise-like aching, burning, tightness
- radiation to shoulder, neck, jaw, inner arm, epigastrum (can occur without chest component); band like discomfort
- relatively predictable
- lasts 3-15 min
- abates when stressor is gone or nitro is taken
- Angina: metabolic demand for the heart is higher than what we can get there
- EXERTION related pain that is consistent
- You cant necessarily have no sxs yesterday and then have severe sxs today with angina
- Chest pain, exertional component, fixed component
6
Q
Unstable angina
A
- Class I: no angina with ordinary physical activity, angina with strenuous or prolonged exertion
- Class II: Early-onset limitation of ordinary activity, angina may be worse after meals, in cold temp, or with emotional stress
- Class III: marked limitation of ordinary activity
- Class IV: inability to carry out any physical activity without chest discomfort, angina occurs during rest
- Unstable angina – when the CP gets more severe
- Chronic progressive problem that occurs over decades
- Unstable is class 3 or class 4 angina
- If you have anginal sxs with less than two blocks or two flights of stairs, that’s REALLY concerning
7
Q
ST segment elevation MI
A
- Occlusive myocardial infarction resulting in abrupt cessation of coronary flow distal to site of thrombosis
- ECG is characterized by ST segment elevation in an anatomic distribution
- Troponin increase is a marker of myocardial infarction
- ST elevation MI: occlusive MI is when the vessel is completely occluded and the myocardium distal to the occlusion suffers and dies
- For the most part, occlusion happens when you have ST segment elevation MI, but sometimes it happens with NSTEMI
8
Q
Non-ST segment elevation MI
A
- Troponin increase in the absence of strict ECG criteria for STEMI
- 2/3rd of the time, this occur in the setting of demand ischemia (i.e. situation where myocardial blood demand outstrips blood supply)
- 1/3rd of the time, this occurs with occlusive myocardial infarction without clear STEMI on ECG
- NSTEMI is a spectrum of disease. Diagnosed by troponin and EKG
- Two different causes: EKG just doesn’t show the elevation
- The vast majority of the Mis are supply and demand mishaps
- Example: severe sepsis – hypotensive, cool, clammy, shock, there is global hypoperfusion to the whole body including the heart – this can result in a troponin leak. This is an MI that was caused by sepsis
- If anemia is causing the problem, the fix is fixing the anemia. Same with sepsis, fix the sepsis!
9
Q
Cardiogenic Shock
A
- Inadequate tissue perfusion in the setting of profound cardiac dysfunction
- Hypotension (SBP < 80-90 mmHg or MAP < 30 mmHg compared to baseline)
- Cardiac index < 1.8 L/min per m2
- Adequate or elevated filling pressures
-Cardiogenic shock: if you’ve had an MI in the past and then you have another MI later on, then the total damage to the heart can be around 40%!
10
Q
CAD risk factors
A
- male >45, female >55
- trans fats and cholesterol
- family hx
- smoking
- high blood pressure
- diabetes
- Obesity, sedentary lifestyle, mental stress, depression, insomnia
- Amphetamine/Cocaine use
- ESRD
- Connective tissue disorders (e.g. SLE, RA)
- Vasculitis
- HIV and HAART medications
- Trauma
11
Q
AMI risk factors
A
- Being alive
- Not being dead
- Having a heart
- Risk increases after age 40 in men and after age 50 in women
- Troponin is better than your history!
12
Q
Myocardial infarction
A
- pain - sudden onset, substernal, crushing, tightness, severe, unrelieved by nitro, may radiate to back, neck, jaw, shoulder, arm
- dyspnea
- syncope (decreased BP)
- nausea
- vomiting
- extreme weakness
- diaphoresis
- denial is common
13
Q
atypical populations
A
- women
- elderly
- DM
- ESRD
- demetia
- psych
- language barrier
14
Q
Atypical symptoms of MI without chest, arm, neck, or jaw discomfort
A
- N/V
- cold sweats
- SOB
- fatigue
- syncope
- cold, clammy skin
- back pain
- palpitations
15
Q
Nitro administration
A
-Cannot be used by itself to determine CAD bc It can relieve non ischemic pain too
16
Q
Low risk chest pain
A
- Pleuritic pain (i.e., sharp or knifelike pain brought on by respiratory movements or cough)
- Pain reproduced with movement or palpation of the chest wall or arms
- Primary or sole location of discomfort in the middle or lower abdominal region
- Pain that may be localized at the tip of 1 finger, particularly over the left ventricular apex or a costochondral junction
- Very brief episodes of pain that last a few seconds or less
- Pain that radiates into the lower extremities
17
Q
Who needs an ECG
A
-CART analysis of >3 million chest pain ED visits
- Age >30 with chest pain
- Age >50 with dyspnea, AMS, upper extremity pain, syncope, weakness
- Age >80 with abdominal pain, nausea/vomiting
- Use clinical judgment
-SEN 92% for STEMI, NPV 99.98%
18
Q
Troponin
A
- Specific for cardiac muscle
- Rise within hours of symptoms and remain elevated for up to 1-2 weeks
- Be familiar with lowest level of detection and lowest level of AMI
- Assay can detect 0.04 ng/mL
- Lab reports values ≥ 0.10 ng/mL
- AMI diagnostic at ≥ 0.30 ng/mL
-Current Gold Standard for AMI
19
Q
Best test for diagnosing unstable angina?
A
Nuclear imaging
20
Q
initial ED tx of ACS
A
- IV – establish 1-2 large bore peripheral IV’s
- O2 – provide supplemental O2 by nasal cannula if hypoxia is present
- Cardiac monitor with automated HR and BP recording
21
Q
Medical therapy
A
- Aspirin – 162mg, non-enteric coated, chewed
- Significant mortality benefit 2.4%-5.2%
- Other antiplatelet agents
- Clopidogrel preferred*
- LMWH/heparin
- Small benefit when used as a bridge to more definitive intervention
-Analgesia – opiates
- Nitrates
- Avoid if SBP < 90 mmHg, suspected RV infarct, recent phosphodiesterase inhibitor
- Statins
- ?attenuation of inflammatory response that occurs with ACS
- Beta-blockers
- Avoid IV beta-blockers in first 24 hours; improved mortality when PO given on day #2
- ACE inhibitors
- Administer when hemodynamics stabilize
22
Q
Life-threatening causes of chest pain
A
- Acute Coronary Syndrome
- Pulmonary Embolism
- Aortic Dissection
23
Q
Pulmonary Embolism
A
- Obstruction of pulmonary artery or one its branch by clot/fat/air/tumor
- Typically clot originates in deep veins or the leg, pelvis, or arm
- Clinical presentation is related to timing and location of pulmonary embolism
- Timing: acute, subacute, or chronic
- Location: saddle, lobar, segmental, or subsegmental
24
Q
Risk factors for PE
A
- Prolonged immobilization (e.g. long distance travel)
- Surgery (especially orthopedic surgery of the lower extremity)
- Central venous catherization
- Trauma
- Pregnancy and immediate post-pregnancy period
- Cancer
- Personal or family history of hypercoagulability
- Exogenous estrogen or testosterone
-A significant number of patients with PE have no identifiable risk factors at the time of diagnosis
25
Clinical Presentation of PE: sxs
- Dyspnea at rest or with exertion (73%)
- Onset is seconds to minutes (72%)
- Pleuritic chest pain (66%)
- Cough (37%)
- Unilateral leg swelling or pain (44%)
- Wheezing (21%)
- Hemoptysis (13%)
-Rarely, patients present with shock, arrhythmia, or syncope
26
Clinical Presentation of PE: signs
- Tachypnea (70%)
- Unilateral leg swelling or tenderness (47%)
- Tachycardia (30%)
- Pulmonary rales (51%)
- Decreased breath sounds (17%)
- Jugular venous distension (14%)
- Hypotension (8%)
- Fever (3%)
27
PE rule-out criteria
- age <50yo
- pulse <100 bpm
- SaO2 >/= 95% on room air
- no hemoptysis
- no exogenous estrogen use
- no prior venous thromboembolism
- no surgery or trauma requiring hospitalization within the past 4 weeks
- no unilateral leg swelling
28
Diagnostic evaluation of PE
-Use PERC and Wells criteria to risk stratify
- Wells Score
- PE unlikely (0-4 pts): PERC score or d-dimer (Overall 12% incidence of PE, Use age-adjusted d-dimer in patients > 50yrs)
- PE likely: CT PE chest (Overall 37% incidence of PE)
- If you sent a d-dimer to evaluate for PE, and the d-dimer is (+), then CT PE chest
- Hemodynamically unstable patients – consider bedside ECHO for RV size and treat accordingly
29
Treatment of PE
-Treatment depends on clinical severity of PE, location of the clot, and underlying coagulation state
- Options
- Heparin or low molecular weight heparin
- Coumadin or novel oral anticoagulant
- Thrombolytics for massive PE (Sustained hemodynamic instability (SPB < 90 mm Hg for 15 min or requirement for vasopressors))
-Prognosis: recurrent thromboembolism, chronic embolic pulmonary hypertension, death
- Disposition
- PESI or sPESI score
- In general, hemodynamically stable patients can be treated as outpatients
30
Aortic dissection
- Tear in aortic intima creates a false aortic lumen – which can lead to aortic rupture
- Chronic HTN is the most important predisposing factor
- Stanford classification
- Type A: ascending aorta
- Type B: descending aorta
Variants
- Aortic intramural hematoma
- Intimal tear without hematoma
- Penetrating atherosclerotic ulcer
31
AD detection: High risk conditions
- marfan syndrome
- connective tissue disease
- family hx of aortic disease
- known aortic valve disease
- recent aortic manipulation
- known thoracic aortic aneurysm
32
AD detection: high risk pain features
-chest, back, or abdominal pain described as the following: abrupt in onset/severe in intensity AND ripping/tearing/sharp or stabbing quality
33
AD detection: high risk exam features
- evidence of a perfusion deficit (e.g. pulse deficit, systolic BP differential, focal neurologic deficit - in conjunction with pain)
- murmur of aortic insufficiency (new or now known to be old - in conjunction with pain)
- hypotension or shock state
34
Clinical presentation of AD
- Abrupt-onset, severe chest or back pain
- Sharp, knife-like
- Ripping or tearing
- Syncope
- On exam, a pulse deficit may be appreciated
- New diastolic heart murmur (aortic regurgitation)
- Focal neurologic deficit (e.g. stroke, ALOC, Horner syndrome, hoarseness, acute paraplegia from spinal cord ischemia)
- Hypotension
- May be related to cardiac tamponade, aortic valve regurgitation, acute myocardial infarction/complete heart block, hemothorax or hemoperitoneum
35
Diagnostic evaluation of AD
- CXR – wide mediastinum in 60-70% of cases
- D-dimer – use a cutoff of 500 ng/mL
- SEN 97%, SPE 56%, NPV 96%
- ADD Risk Score: 0-1pts
- Send d-dimer – CTA chest only if d-dimer > 500 ng/mL
- ADD Risk Score: 2-3pts
- CTA chest
- The finding of wide mediastinum on CXR + 1pt by ADD – CTA chest
- Hemodynamically unstable patients – consider bedside ECHO for detection of aortic dissection
36
Treatment of AD
Goals:
- HR < 60 bpm, SBP 100-120 mmHg
- Esmolol or labetalol preferred
- Nicardipine is 2nd line therapy
- Use opiates for pain control
-Type A Aortic Dissection – keep patient alive by decreasing BP and HR until patient can be evaluated by thoracic surgery
- Type B Aortic Dissection – medical management +/- thoracic surgery consult
- If no perfusion deficit, then admit to ICU
- If perfusion deficit is present, then thoracic surgery
-Know that you want to get HR less than 60 and BP less than 100-120
37
ACS summary
- Know typical and atypical symptoms
- Have a low threshold for sending a troponin
-CAD risk factors are helpful to determine if a patient has angina/unstable angina
- The ECG is key
- Trop don’t lie!
- Cath lab
- Medical management: ASA, NTG, heparin, b-blockers, statin, etc.
38
PE summary
- Hypoxia and/or tachycardia are more likely associated with PE
- Use PERC and Wells criteria to risk stratify patients
- A (-) d-dimer rules out PE in low risk patients
- CT PE protocol
- Use sPESI to risk stratify
- Start anticoagulation if uncomplicated
- Thrombolytics if shock is present
39
AD summary
- Abrupt onset of severe vascular pain – patient looks uncomfortable
- Use AD detection risk score and CXR to stratify patients
- A (-) d-dimer rules out AD in low risk patients
- CTA Chest
- Keep the patient alive until surgery
- HR goal: < 60 bpm
- BP goal: 100-120 mm Hg
