Pt w/ Chest Pain

Question 1

Initial differential diagnoses

Answer 1

ACS Aortic Dissection MI Pneumothorax MSK pain PE Pericarditis Pneumonia

Question 2

ACS - characteristic presentation

Answer 2

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

Question 3

Features of examination of ACS

Answer 3

Tachycardic, low BP

Question 4

Silent MIs - who gets them - how do they present

Answer 4

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

Question 5

Aetiology and RFx for ACS

Answer 5

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

Question 6

Investigations for potential MI

Answer 6

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

Question 7

Troponin findings - And other biochemical markers

Answer 7

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%)

Question 8

ECG findings in MI

Answer 8

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

Question 9

Initial emergency management for MI

Answer 9

• Reassure
• Oxygen – maintain sats >94%; 2-4L/min
• Morphine – Diamorphine 5-10mg slow IV infusion; repeat after 5-10 min if necessary; give anti-emetic with first dose
• Aspirin – 300mg PO + Antiemetic Metaclopramide 10mg IV + Metoprolol 1-2mg
• Nitrates – GTN spray or buccal or sublingual if hypertensive
• Clopidogrel – 300mg PO ; unless contraindicated
• Enoxaprin/Fondaparinux - 2.5mg SC
• ECG

Question 10

Indication for thrombolysis in ACS Timing thrombolysis Choice of thrombolytic agent

Answer 10

• 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

Question 11

What if thrombolysis is contraindicated

Answer 11

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

Question 12

Presentation of Aortic dissection + symptoms based on location of dissection

Answer 12

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)

Question 13

Causation and RFx for aortic dissection

Answer 13

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

Question 14

Examination findings in aortic dissection

Answer 14

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

Question 15

Investigations for aortic dissection (bloods, imaging: first-line & gold standard)

Answer 15

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

Question 16

Initial management for aortic dissection

Answer 16

• 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)

Question 17

Presentation of PE

Answer 17

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

Question 18

Examination findings in PE

Answer 18

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

Question 19

Aetiology and RFx for PE

Answer 19

2ry to DVT RFx - recent surgery, pregnant, other immobility, chemotherapy, COCP, active malignancy, personal or family history

Question 20

Investigations for suspected PE

Answer 20

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

Question 21

D-Dimer - interpretation

Answer 21

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)

Question 22

Well’s score mnemonic C3PO R2D2

Answer 22

Cancer (active), Calf diameter increase >3 cm, Collateral superficial veins visible

Pitting oedema, Previous DVT documented

Oedema of the whole leg, tenderness of the calf

Recent surgery (<4 weeks), Recent immobilization (>3 days)

Different diagnosis more likely (subtract 2 points).

Question 23

What is CTPA?

Answer 23

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

Question 24

Presentation of pneumothorax

Answer 24

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

Question 25

Examination findings in pneumothorax

Answer 25

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

Question 26

Aetiology and RFx for pneumothorax

Answer 26

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

Question 27

Investigations for pneumothorax

Answer 27

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

Question 28

Management of pneumothorax

Answer 28

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

Question 29

D/c and admission decision in pneumothorax

Answer 29

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

Question 30

Pericarditis presentation

Answer 30

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

Question 31

Examination findings in pericarditis

Answer 31

Pericardial friction rub is pathognomonic - may be positional and transient

Question 32

Investigations for pericarditis

Answer 32

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

Question 33

ECG findings in pericarditis

Answer 33

Saddle shaped ST segment ST segment depression in aVR

Question 34

Management of pericarditis

Answer 34

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

Question 35

Causes of pericarditis

Answer 35

Can be idiopathic but cause is often infectious

Question 36

NSTEMI: what is it?

Answer 36

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

Question 37

NSTEMI presentation

Answer 37

Surrounding angina symptoms - REST angina - INCREASING angina - NEW angina

Question 38

NSTEMI Management

Answer 38

Very similar to that for STEMI - MONAT - Morphine for analgesia - Oxygen - Nitrates - Aspirin 300mg - Ticagrelor or clopidogrel Monitor abs and ECG