Pt w/ Chest Pain Flashcards
Initial differential diagnoses
ACS Aortic Dissection MI Pneumothorax MSK pain PE Pericarditis Pneumonia
ACS - characteristic presentation
Crushing central chest pain that might radiate to arm, neck, jaw (commonly on LHS). - can radiate through to back
- this pain is not taken away (or not permanently) by sub-lingual GTN
Exertional pattern of onset.
Associated with nausea, vomiting, sweating, clammy, anxiety, palpitations
PMH of angina, IHD / other thrombotic events
Features of examination of ACS
Tachycardic, low BP
Silent MIs
- who gets them
- how do they present
MIs that do not present with characteristic crushing central chest pain
- diabetic and elderly get them
- usually present as being very nauseous or vomiting, or have dyspnoea (acute pulmonary oedema), have a sensation of indigestion
Aetiology and RFx for ACS
Usually due to thrombosis formation in coronary artery - this is most commonly the Left Anterior descending Artery
RFx = Obesity, high blood pressure, smoking, high cholesterol, diabetes, diet
Investigations for potential MI
Bloods: FBC, Troponin, U&E, glucose
ECG
Consider CXR
Troponin findings
- And other biochemical markers
Troponin start to rise by 3 hours (no point taking before) if troponin isn’t raised by 6 hours ACS is unlikely
- Creatinine Kinase is another marker. (CK-MB more specific for cardiac disease). Peak levels occur at 24 hours but rise might come sooner. Not very sensitive (high false positives - approx 15%)
ECG findings in MI
STEMI - ST elevation
- LATERAL = I, aVL, V5, V6
- INFERIOR = II, III, aVF
- ANTERIOR = V3, V4
- SEPTAL = V1, V2
- **NSTEMI
- Pathological q waves
- T wave inversion
- PR segment elevation / depression
Initial management for MI
- Oxygen (but ONLY if sats <94%)
- Analgesia: Diamorphine 2.5-10mg slow IV infusion OR Nitrates
- Aspirin 300mg PO, can consider giving 300mg clopidogrel or ticagrelor 180mg AS WELL
- OTHERS: metaclopramide (10mg IV), B-blocker (metoprolol 1-2mg), heparin (enoxaparin bolus)
Indication for thrombolysis in ACS
Timing thrombolysis
Choice of thrombolytic agent
- typical cardiac pain with previous 12h and continuous ST elevation in two ECG LEADS
- Cardiac pain with new LBBB
Timing: as soon as possible especially within 4 hours. Can be given 12-24h from onset of initial pain if symptoms or ECG changes persist
Agent: rtPA are the ones that are usually given
What if thrombolysis is contraindicated
Percutaneous Coronary Intervention - PCI. This is indicated in lots of patients and in Leeds is often used before thrombolysis due to bleeding risk
Presentation of Aortic dissection
Sudden, tearing pain that radiates to back (inter scapular). Most severe at its onset
Other symptoms pertain to where dissection might be
- anuria - renal failure
- unequal pulses in arms or legs
- acute limb ischaemia or paraplegia
- in shock (low BP high HR)
Causation and RFx for aortic dissection
Caused by tear in aortic endothelium (not necessarily all the way through might just bleed between layers of endothelium) - DeBakey classification of where the bleeding is
- Smoking, HTN, Ehlers-Danlos and Marfans (connective tissue disorders), deceleration trauma (RTA)
…unilateral tongue weakness after car crash with whiplash injury = carotid artery dissection
Examination findings in aortic dissection
Most patients are hypertensive (hypotension can occur in ascending aortic dissection) - make sure to record BP in both arms
- aortic valve regurgitation
Investigations for aortic dissection
Bloods: FBC, U&E, Glucose, Trop (rule out MI), cross match for 10U
ECG: normal or with LVH abnormalities
CXR: subtle changes - upper mediastinum widening
Echo - aortic root dilation / TOE (TOE is first line usually)
MRI ANGIOGRAPHY - gold standard of diagnosis
Initial management for aortic dissection
- Manage in resus
- Large bore cannulas (get bloods) cross match 10U
- ICU input - insert arterial line
- Analgesia - Diamorphine 2.5-10mg IV slow (5min infusion)
- If ascending aorta then immediate surgical repair
- if descending must keep BP down to prevent rupture. Labetalol IV (aim for systolic 100-120mmHg)
Presentation of PE
Sudden onset - Chest pain, breathlessness, haemoptysis, dizziness
Prev. red, swollen, hot leg
Examination findings in PE
Tachycardia, Hypotension, tachypnoeic, raised JVP, pleural rub or effusion, lower limb thrombophlebitis
Aetiology and RFx for PE
2ry to DVT
RFx - recent surgery, pregnant, other immobility, chemotherapy, COCP, active malignancy, personal or family history
Investigations for suspected PE
D-dimer Baseline - FBC, U&E, group and save, clotting ABG ECG CXR (wedge infarcts) CTPA V/Q scan Calculate Well's score
D-Dimer - interpretation
Highly sensitive but not specific meaning it’s good at ruling people out but not ruling people in
- if it’s low it means they definitely don’t have one but even if its high doesn’t mean they necessarily have it (just a clot break down product)
Calculating a Well’s Score
Helps you decide whether PE should be primary diagnosis
- active cancer or within 6/12 - 1
- Paralysis or recent immobilisation of LL - 1
- Recent bed-ridden (>3days) or surgery <4 weeks - 1
- Localised tenderness over vein - 1
- Entire leg swollen - 1
- Calf circumference >3cm large than other side >10cm below tibial tuberosity
- Pitting oedema > asx leg - 1
- Collateral superficial veins - 1
- Other dx more likely - -2
What is CTPA?
Dye is put through pulmonary arteries and this is then visualised on CT
MUST DO if suspect PE
- Sensitivity and Specific >90%
***pulmonary angiography is gold standard
Management of PE
Stabilise
- Start IV fluids (2 wide bore cannulas - get baseline bloods + d-dimer)
- Give oxygen 15L NRBM
- Thrombolysis - Alteplase 100mg over 2h or streptokinase 250,000U
- LMWH: Target INR 2-3
- Analgesia: NSAIDs. Use opioid with caution (vasodilation may worsen hypotension)
- Consider DOAC for maintenance therapy
Presentation of pneumothorax
Sudden onset of pleuritic chest pain, SOB. Tension - 2ry to trauma
Examination findings in pneumothorax
Unequal expansion
Hyper-resonance
Decreased breath sounds and decreased tactile vocal fremitus and vocal resonance. Deviation of mediastinum and trachea in tension
Tachypnoea and tachycardia
Aetiology and RFx for pneumothorax
Primary - thin, young, tall men.
Secondary - to lung pathology e.g. pneumonia, asthma, COPD
Tension - trauma creating one way valve
Investigations for pneumothorax
ABG
CXR - small pneumothorax <2cm between lung and chest wall. Large = >2cm
ECG (rule out)
Baseline bloods - FBC (useful to look for infection), U&E
Management of pneumothorax
ASPIRATION - mid clav line 2nd IC space with 16G needle - large 1ry pneumothoraces even if asx, all small 2ry pneumothoraces if asx and <50yo
CHEST DRAIN - mid-ax line 5th IC
- 1ry pneumothoraces in whole aspiration has failed, all other 2ry pneumothoraces
D/c and admission decision in pneumothorax
Small, first episode, primary with no significant dyspnoea or chronic lung disease can usually be discharged - follow up in chest clinic in 10-14 days + safety netting
Everyone else needs admission for observation
Pericarditis presentation
Central chest pain, often pleuritic, relieved by sitting forward
Sometimes SOB
Symptoms of underlying ideas (fever, cough, rash)
Examination findings in pericarditis
Pericardial friction rub is pathognomonic - may be positional and transient
Investigations for pericarditis
ECG Echo FBC, ESR and CRP Trop and CK (rule out) CXR - large heart, pulmonary oedema If indicated - Blood cultures, TFTs
ECG findings in pericarditis
Saddle shaped ST segment
ST segment depression in aVR
Management of pericarditis
admit for observation
NSAIDS are mainstay - ibuprofen well tolerated and improves cardiac flow. PPI cover
Steroids - prednisolone can be used if pain doesn’t settle
Oral anticoagulants should be discontinued to reduce risk of haemopericardium
Address underlying cause
Causes of pericarditis
Can be idiopathic but cause is often infectious
NSTEMI: what is it?
Non-ST elevation MI. Closely related to unstable angina (NSTEMI is angina but with myocardial damage)
NSTEMI presentation
Surrounding angina symptoms
- REST angina
- INCREASING angina
- NEW angina
NSTEMI Management
Very similar to that for STEMI - MONAT
- Morphine for analgesia
- Oxygen
- Nitrates
- Aspirin 300mg
- Ticagrelor or clopidogrel
Monitor abs and ECG
