Lecture 5: Chest Pain in the ED Flashcards
What is the primary question to consider when someone presents with chest pain?
Is it cardiac or not?
What are the two types of chest pain in terms of nerve fiber?
- Visceral: heart, vessels, esophagus, visceral pleura, often described as difficult to describe and localize
- Somatic: Chest wall, from the dermis to parietal pleura, often described easily and precisely located
How does someone typically describe visceral chest pain?
- Discomfort
- Heaviness
- Pressure
- Tightness
- Aching
How does someone typically describe somatic chest pain?
- Sharp
- Stabbing
- Scratching
- Non-radiating
What are the red flags that require immediate eval in triage?
- Abnormal vitals
- Concerning EKG findings
- Hx prior CAD
- Multiple ASCVD RFs: Age, HTN, tobacco use, HLD, DM, obesity, FHx, ASCVD, sedentary
- Abrupt onset or severe or with DOE
Time is muscle!
Initial managment for chest pain in the ED
- Bed
- Cardiac monitoring + 2 IVs
- EKG within 10 mins
- Monitor/treat vitals
Keep O2 above 95% (for this course)
What are the 6 top DDx that present with chest pain?
- ACS
- Aortic Dissection
- PE
- Severe PNA
- Tension Pneumo
- Esophageal rupture
Alternative: PETMAC for 6 most deadly causes of chest pain
PE
Esophageal rupture
Tension Pneumo
MI/ACS
Aortic Dissection
Cardiac Tamponade
4 Primary DDx that present with visceral pain
- Unstable angina
- MI
- Aortic Dissection
- Esophageal rupture
3 Primary DDx with present with pleuritic chest pain
- PE
- PNA
- Spontaneous Pneumo
What is important to keep in mind when doing an EKG?
It does not r/o ACS or life-threatening causes of chest pain.
Do serial if pt still in pain but EKG was normal.
First-line cardiac enzyme lab
Troponins, which elevate as quickly as 4h.
I & T are the troponins we measure.
Trops have 100% specificity!
Peaks in 24-48h remaining elevated for days.
Pitfall of troponins
Not reliable in detection of re-infarction
It takes a while for it to go back down!
Use CK-MB instead, which normalizes in 48-72h.
When is emergent echo indicated?
- Aortic dissection if not CTA available
- Cardiac tamponade
You need a very skilled US person + someone that can interpret it.
How do we determine to admit for chest pain?
HEART scoring, which determines MACE in the following 6 weeks (Major adverse cardiac event)
Elkins said just know the score ranges at the bottom.
Minimum HEART score for admittance? Invasive therapy?
- Admittance: 4-6
- Invasive: 7-10
0-3 = discharge byebye
What is HTN crisis?
- SBP >180
- AND/OR
- DBP > 120
HTN urgency vs HTN emergency
- Urgency = HTN crisis without end-organ damage
- Emergency = HTN crisis with end-organ damage
What are the 5 end-organs?
- Brain
- Heart
- Aorta
- Kidneys
- Eyes
What signs suggest HTN retinopathy?
- Papilledema
- Flame-shaped hemorrhages
- Macular exudates
- Cotton-wool spots
DOC for treating HTN urgency with no hx of HTN
HCTZ daily
Management of BP in HTN emergency
- IV antiHTNs
- Reduction of SBP by a max of 25% in the first hour (3 exceptions)
- If stable, reduce to 160/100 over 2-6 hours, then normal.
The 3 exceptions to lowering SBP by 25%:
Aortic dissection
Acute ischemic stroke
ICH
If a patient is having pre-eclampsia and HTN emergency, what is the go-to IV AntiHTN?
Hydralazine
For a patient with renal insufficiency in HTN emergency, what is the DOC?
Fenoldopam
D1 receptor agonist, unique
For a patient with aortic dissection, what are the two primary DOC for lowering BP?
- Esmolol
- Labetalol
Features of esophageal rupture/Boerhaave syndrome
- Tear/rupture of distal (MC) 1/3 of esophagus, causing pneumomediastinum
- MCC: forceful vomiting/coughing
- Posterolateral wall of distal esophagus (90% of cases)
How does someone with esophageal rupture present?
- Sudden onset substernal chest pain post vomiting episode
- Radiation into neck or abd, worsened by neck flexion, breathing, and swallowing
- Fever/diaphoresis/SOB/Tachycardia/subcutaneous emphysema
What is Hamman’s crunch/sign?
Mediastinal crunch (rice krispies) under the apex of the lung.
Subcutaneous emphysema; seen in Boerhaave syndrome
What can be seen on CXR for esophageal rupture?
- Pneumomediastinum
- Pneumoperitoneum
Management of Esophageal rupture
- Airway
- NPO/IVF
- ABX: Unasyn or Zosyn (Clinda + cipro)
- NG/OG tube
- Surgery consult
What does cardiac tamponade affect specifically in the heart?
Affects the right side of the heart
R side is lower than L slightly
Why does hypovolemia cause cardiac tamponade to develop slower?
Hypovolemia lowers ventricular filling pressure
Clinical presentation of cardiac tamponade
- DOE and rest
- Tachycardia
- Hypotension with narrow PP
- Pulsus paradoxus (Drop of SBP > 10-20 during inspiration)
- JVD
- Distant heart sounds
What is Becks’ triad?
- Hypotension
- JVD
- Decreased heart sounds
Cardiac tamponade
Most sensitive and specific diagnostic tool for cardiac tamponade?
TTE
EKG findings suggest of cardiac tamponade
- Lower voltage QRS
- Electrical alternans
- Diffuse STE (pericarditis as underlying cause)
CXR finding for cardiac tamponade
Enlarged cardiac silhouette
Emergent procedure for unstable cardiac tamponade
Pericardiocentesis
