The Evaluation of Chest Pain in the Emergency Setting - Brown Flashcards
Pathogenesis of Chest Wall Pain
- irritation
- trauma
- compression of structures
- muscles
- cartilaginous structures
- nerves
- bones
Gastroesophageal Reflux
*Describe the presentation and characteristics of gastrointestinal causes of chest pain *
- substernal burning and pain
- starts in epigastrium and radiates upward
- related to consuming large meal, lying down, or bending over
- relieved by antacid or food
Treatment Algorithm: strongly suspicious for injury
start adjunctive treatments
- B-adrenergic receptor blockers
- nitroglycerine
- heparin
- ACE inhibitors
time from onset of symptoms
- < 12 hours - select a reperfusion strategy
- angiography
- PCI
- CT surgery
- fibrinolytic therapy
- > 12 hours - not candidate for fibrinolytics
- treat as non-ST elevated AMI (cath, revascularization)
Chest Pain - Musculoskeletal or Nerve Origin
Describe the presentation and characteristics of chest pain that is musculoskeletal or nerve origin
- lasts few seconds to days, months, maybe longer
- sharp, dull or aching
- aggravated by deep breathing or cough
- point-tenderness on palpation
- may be dermatomal
- occurs with movement
- bone pain is well localized
Costochondritis
*Describe the presentation and characteristics of chest pain that is musculoskeletal or nerve origin *
- sharp, well localized pain
- most intesne at costochondral junction
- palpation reproduces pain
- warmth, erythema and swelling
- aggravated by deep breathing and cough
Pulmonary Embolism
*Describe the presentation and characteristics of pulomonary causes of chest pain *
Risk Factors:
- immobility
- recent surgery
- pregnancy or oral contraceptive use
- large bone fracture
- malignancy
- DVT or prior PE
- CHF
- COPD
- obesity
- hypercoagulability
Presentation:
- pleuritic chest pain
- sudden onset dyspnea
- tachypnea and tachycardia
- hypotension
- hemoptysis possible
Examination:
- rales (crackles) and pleural friction rub
Absolute Contraindications to Fibrinolytic Therapy
List the indications and contraindications for thrombolytic therapy
- history of intracranial hemorrhage
- known intracranial neoplasm or vascular lesions
- active bleeding or known bleeding disorder
- embolic stroke within 3 months
- suspected aortic dissection
- significant facial or head trauma within 3 months
Options for testing of CAD
- treadmill - exercise tolerance test (ETT)
- stress myocardial perfusion imaging
- stress echo
NSTEMI
Describe the classification of Acute Coronary Syndrome and the inital evaluation based upon 12-lead ECG findings
- occluding thrombus sufficient to cuase tissue damage and mild myocardial necrosis
- ECG:
- can look normal
- ST depression +/- T wave inversion
- Elevated cardiac enzymes
non-invasive testing for chest pain
Describe common non-invasive tests used to evaluate chest pain.
- Electrocardiogram
- Exercise Treadmill Testing
- Stress Myocardial Perfusion Imaging
- Nuclear stress testing
- Pharmacologic stress
- adenosine, dipyridamole, dobutamine
- sestamibi
- Stress Echocardiography
History and Physical Exam of patients with Chest Pain
- Describe the diagnostic evaluation of patients with chest pain including H & P, diagnostic tests, initial management and patient education*
History
- if emergent brief targeted history, get more details later
- OLD CHARTS
Physical Exam
- asses level of stress and anxiety
- BP in both arms (doppler if needed)
- postural BP
- skin
- pallor, cyanosis
- jaundice
- herpes zoster rash
- eyes - fundoscopic exam
- neck
- lymphadenopathy
- thyromegaly
- tracheal shift
- JVD
- carotid bruits
- chest wall
- signs of trauma
- heaves or lifts
- palpate for tenderness
- complete heart exam
- extra heart sounds
- murmurs, clicks, hums, rubs
- irregularities
- arrhythmias
- lungs
- equal breath sounds, plerual rub
- crackles
- ronchi
- wheezes
- Abdomen
- bowel sounds and bruits
- tenderness, masses
- organomegaly
- ascitis
- Lower Extremities
- femoral and peripheral pulses
- cyanosis
- Musculoskeletal and Neurological
- patients with pain on motion
- focus on focal tenderness
- motor or sensory deficits
Cardiopulmonary or Vascular Differential Diagnosis of Chest Pain
Give a broad differential diagnosis of chest pain listed by organ system.
- MI
- Aortic Dissection
- Pericarditis
- Pulmonary Embolism
- Valvular Disease
- Aortic Stenosis
- Mitral Valve Prolapse
- Bacterial Endocarditis
- Hypertrophic Obstructive Cardiomyopathy
- Myocarditis
Classification of Acute Coronary Syndromes
Describe the classification of Acute Coronary Syndrome and the inital evaluation based upon 12-lead ECG findings
- Unstable angina pectoris
- non-ST segment elevation MI (NSTEMI)
- ST segment elevation (STEMI)
Pleural Causes of Chest Pain
Describe the presentation and characteristics of chest pain that is pleural in origin
- worsened by deep inspiration or coughing
- spasm secondary to:
- cold weather
- increased activity
gastrointestinal causes of chest pain
give a broad differential diagnosis for chest pain listed by organ system
- Gastroesophageal reflux
- Esophageal spasm
- Cholecystitis
- Peptic ulcer disease
- Pancreatitis
GI Disorders are associated with eating, relief with antacids.
Fibrinolysis Indications
List the indications and contraindications for thrombolytic therapy
- ST segment elevation > 1 mm in two contagious leads
- new LBBB
- symptoms consistent with ischemia
- symptom onset less than 12 hours prior to presentation
Unstable Angina
Describe the classification of Acute Coronary Syndrome and the inital evaluation based upon 12-lead ECG findings
- non-occlusive thrombus
- ECG: non-specific ECG; ECG can look normal
- normal cardiac enzymes
Nerve Root Compression
Describe the presentation and characteristics of chest pain that is musculoskeletal or nerve origin
- results in pain and motor/sensory deficits
- numbness or tingling in neck, chest, upper arm
AMI Symptoms in African Americans
- abdominal pain
- absence of chest pain
- dizziness/weakness
- fatigue
- hot and flused
- indigestion
- palpitations
AMI Symptoms in the Elderly
- absence of chest pain
- diaphoresis
- dyspnea
- faintness
- syncope
- nausea
- vomiting
Diagnostic Testing in patients with Chest Pain
Describe the diagnostic evaluation of patients with chest pain including H & P, diagnostic tests, initial management and patient education
based on the data from the H &P
- pulse oximetry
- cardiac enzymes
- CBC and complete metabolic panel
- 12 lead ECG
- chest x ray
- others to consider
- echocardiogram
- mitral valve prolapse
- valvular disorders
- aortic aneurysm or dissection
- CT with contrast
- TE echo
- aortic angiography
- cardiac catheterization
- stress echo
- spiral CT
- pulmonary embolism
- echocardiogram
“Atypical” Chest Pain
- doesn’t fit a common pattern
- no abnormal exam or diagnostic findings
- usually self-limited and resolves on own
- diagnosis of exclusion