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Year 4 ACC > Pt w/ Chest Pain > Flashcards

Pt w/ Chest Pain Flashcards

1
Q

Initial differential diagnoses

A 
ACS
Aortic Dissection
MI
Pneumothorax
MSK pain 
PE 
Pericarditis 
Pneumonia
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2
Q

ACS - characteristic presentation

A

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

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3
Q

Features of examination of ACS

A

Tachycardic, low BP

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4
Q

Silent MIs

  • who gets them
  • how do they present
A

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
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5
Q

Aetiology and RFx for ACS

A

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

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6
Q

Investigations for potential MI

A

Bloods: FBC, Troponin, U&E, glucose
ECG
Consider CXR

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7
Q

Troponin findings

- And other biochemical markers

A

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%)

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8
Q

ECG findings in MI

A

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
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9
Q

Initial management for MI

A
  • 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)
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10
Q

Indication for thrombolysis in ACS

Timing thrombolysis

Choice of thrombolytic agent

A
  • 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

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11
Q

What if thrombolysis is contraindicated

A

Percutaneous Coronary Intervention - PCI. This is indicated in lots of patients and in Leeds is often used before thrombolysis due to bleeding risk

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12
Q

Presentation of Aortic dissection

A

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)

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13
Q

Causation and RFx for aortic dissection

A

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

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14
Q

Examination findings in aortic dissection

A

Most patients are hypertensive (hypotension can occur in ascending aortic dissection) - make sure to record BP in both arms
- aortic valve regurgitation

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15
Q

Investigations for aortic dissection

A

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

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16
Q

Initial management for aortic dissection

A
  • 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)
17
Q

Presentation of PE

A

Sudden onset - Chest pain, breathlessness, haemoptysis, dizziness
Prev. red, swollen, hot leg

18
Q

Examination findings in PE

A

Tachycardia, Hypotension, tachypnoeic, raised JVP, pleural rub or effusion, lower limb thrombophlebitis

19
Q

Aetiology and RFx for PE

A

2ry to DVT

RFx - recent surgery, pregnant, other immobility, chemotherapy, COCP, active malignancy, personal or family history

20
Q

Investigations for suspected PE

A 
D-dimer 
Baseline - FBC, U&amp;E, group and save, clotting
ABG
ECG
CXR (wedge infarcts)
CTPA 
V/Q scan 
Calculate Well's score
21
Q

D-Dimer - interpretation

A

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)

22
Q

Calculating a Well’s Score

A

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
23
Q

What is CTPA?

A

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

24
Q

Management of PE

A

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
25
Q

Presentation of pneumothorax

A

Sudden onset of pleuritic chest pain, SOB. Tension - 2ry to trauma

26
Q

Examination findings in pneumothorax

A

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

27
Q

Aetiology and RFx for pneumothorax

A

Primary - thin, young, tall men.
Secondary - to lung pathology e.g. pneumonia, asthma, COPD
Tension - trauma creating one way valve

28
Q

Investigations for pneumothorax

A

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

29
Q

Management of pneumothorax

A

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

30
Q

D/c and admission decision in pneumothorax

A

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

31
Q

Pericarditis presentation

A

Central chest pain, often pleuritic, relieved by sitting forward
Sometimes SOB
Symptoms of underlying ideas (fever, cough, rash)

32
Q

Examination findings in pericarditis

A

Pericardial friction rub is pathognomonic - may be positional and transient

33
Q

Investigations for pericarditis

A 
ECG 
Echo
FBC, ESR and CRP
Trop and CK (rule out)
CXR - large heart, pulmonary oedema 
If indicated - Blood cultures, TFTs
34
Q

ECG findings in pericarditis

A

Saddle shaped ST segment

ST segment depression in aVR

35
Q

Management of pericarditis

A

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

36
Q

Causes of pericarditis

A

Can be idiopathic but cause is often infectious

37
Q

NSTEMI: what is it?

A

Non-ST elevation MI. Closely related to unstable angina (NSTEMI is angina but with myocardial damage)

38
Q

NSTEMI presentation

A

Surrounding angina symptoms

  • REST angina
  • INCREASING angina
  • NEW angina
39
Q

NSTEMI Management

A

Very similar to that for STEMI - MONAT

  • Morphine for analgesia
  • Oxygen
  • Nitrates
  • Aspirin 300mg
  • Ticagrelor or clopidogrel

Monitor abs and ECG

Year 4 ACC (24 decks)

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