Chest pain
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Chest Pain. William Beaumont Hospital Department of Emergency Medicine. The things that kill…. Acute MI PE Pneumothorax (ptx) Aortic Dissection Esophageal Rupture (Boerhaave’s). Let’s dive right in …. Chest Pain: what is it?.

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Chest pain

Chest Pain

William Beaumont Hospital

Department of Emergency Medicine


The things that kill

The things that kill…

  • Acute MI

  • PE

  • Pneumothorax (ptx)

  • Aortic Dissection

  • Esophageal Rupture (Boerhaave’s)


Let s dive right in

Let’s dive right in…


Chest pain what is it

Chest Pain: what is it?

65 y/o male complains of substernal chest pressure and tightening that radiates to his left arm, shortness of breath, diaphoresis, and nausea that started while working in the yard.

Pmhx: HTN, high cholesterol

Soc: + tobacco

FHx: father died at 62 of MI


Chest pain what is it1

Chest Pain: what is it?

86 y/o female presents with generalized weakness, mental status changes, vomiting, epigastric pain, and syncope after her last episode of vomiting.

There is no other history as the NH did not feel it was necessary to send her records.


Chest pain what is it2

Chest Pain: what is it?

36 y/o obese, diabetic male presents with weakness, fatigue. shortness of breath whenever he gets off the couch, and “just not feeling right, doc.”

Pmhx: diabetes since his teens, HTN, high cholesterol

FHx: mom – HTN, dad- “had a bad heart”


Acute coronary syndrome acs

Acute Coronary Syndrome (ACS)

  • Includes USA, NSTEMI, STEMI

  • Leading cause of death among adults in the US (about 1 million, 2006)

  • 6 million people present to the ER per year with chest pain, 2 million of these receive the diagnosis of ACS

  • Cost of doing business: $100-120 billion


Risk factors for cad

Typical

Male

Older Age

Tobacco

HTN

DM

High Cholesterol

FHx

Cocaine

Artificial/early menopause

Atypical

DM

Elderly

Female

Nonwhite

Dementia

No history of MI

No history of high cholesterol

CHF

CVA

Risk factors for CAD


Unstable angina usa defined

Unstable Angina (USA) Defined

  • New onset angina occurring with minimal exertion or at rest, worsening of previous angina, increased frequency or duration of attack, and resistance to previous treatment

  • USA should be treated aggressively as it may be the precursor to AMI -> Admit to step down unit, IV NTG (if CP continues), IV Heparin, aspirin

  • ECG: normal/unchanged, nonspecific ST segment changes, or T wave inversions


Acute myocardial infarction ami definition

Acute Myocardial Infarction (AMI)Definition

  • Rise and fall of cardiac biomarkers with the following

    • Ischemic symptoms (critical vessel stenosis with increased myocardial work load or plaque rupture)

    • Development of q waves on ecg

    • ST segment elevation or depression (STEMI and NSTEMI)

    • Coronary artery intervention (lytics or cath lab)

  • Pathologic findings of acute MI


Nstemi definition

NSTEMI Definition

  • Positive cardiac enzymes in the appropriate clinical scenario without ST elevation on the ecg

  • Ecg – normal, t wave inversions, ST segment depressions


Ecg findings of acs

ECG Findings of ACS

  • Hyperacute T waves

  • ST segment elevation of 1 mm

  • ST segment depression – NSTEMI vs reciprocal changes

  • T wave inversions – initial presentation or evolving infarct

  • Q waves – may emerge in the initial hour, but usually develop at 8-12 hours

  • Normal ECG


Injury patterns on the ecg

Injury Patterns on the ECG

Anterior wall MI: ST segment elevation V1-V4

Vessel: LAD


Injury patterns on the ecg1

Injury Patterns on the ECG

Anterior wall MI: ST segment elevation V1-V4


Injury patterns on the ecg2

Injury Patterns on the ECG

Lateral Wall MI: I, aVL, V5, V6

Vessel: variable perfusion of LAD, RCA, LCx


Injury patterns on the ecg3

Injury Patterns on the ECG

Anterolateral with reciprocal changes

Vessels: LAD and 1st diagonal branch


Injury patterns on the ecg4

Injury Patterns on the ECG

Inferior wall MI: II, III, aVF

Vessel: 90% RCA, 10% LCx


Injury patterns on the ecg5

Injury Patterns on the ECG

Posterior Wall MI: V1-V3 depression, tall upright T, tall wide R wave, R/S ratio greater than 1

Vessel: RCA, PDA, LCx


Injury patterns on the ecg6

Injury Patterns on the ECG

Inferior Wall MI with Posterior Wall MI: V1-V3 depression, tall upright T, tall wide R wave, R/S ratio greater than 1

Vessel: RCA, PDA, LCx


Injury patterns what is this

Injury PatternsWhat is this?


Injury patterns pericarditis diffuse st elevation except avr

Injury PatternsPericarditis: diffuse ST elevation except aVR


Moving on

Moving on…

What do you want to order in addition to an ecg for a patient presenting with chest pain, suspected ACS?


Initial evaluation

Initial Evaluation

  • IV, O2, monitor

  • Focused H&P

  • CBC

  • Chem 7

  • CK-MB, troponin, myoglobin

  • CXR

  • PT/PTT

  • Possible d-dimer

  • ? Repeat ecg


Treatment in the ec stemi ami

Treatment in the EC: STEMI/AMI

  • Activate the AMI page and cath lab

  • ASA 325mg po – proven to save lives

  • NTG SL and gtt- reduces preload>afterload, dilates coronary arteries

  • Heparin 60 U/kg bolus then 16 U/kg/hour

  • B Blocker – decrease catecholamine driven tachycardia and contractility, therefore decreasing myocardial oxygen demand


Treatment in the ec stemi ami1

Treatment in the EC: STEMI/AMI

  • Morphine – for persistent pain or anxiety to reduce O2 need, weak sympathetic blocker, preload reducer through venous dilation

  • Glycoprotein IIb/IIIA inhibitors – started in the EC or cath lab for those patients undergoing mechanical coronary intervention

  • Plavix – in consultation with the cardiologist as it prohibits CABG for 5 days


Treatment in the ec stemi ami reperfusion therapy

Treatment in the EC: STEMI/AMIReperfusion Therapy

  • PCI – the 90 minute rule

    • Most people are eligible

    • Decreased risk of bleeding and stroke

    • Higher initial reperfusion rates

    • Defines coronary vasculature and allows for treatment vs. surgical referral

  • t-PA – when PCI cannot be achieved in 90 minutes or is not available at the institution

    • 0-12 hours after symptom onset


Ntg when to think twice

NTG When to think twice?


Ntg be cautious

NTG: be cautious…

  • Bradycardia

  • Hypotension

  • Inferior or posterior wall MI with RV INFARCT

    • Decreased preload will cause sudden hypotension and increase infarct size

    • These patients need fluids to increase preload and help fill the malfunctioning/weakened ventricle


Treatment in the ec usa nstemi

Treatment in the EC: USA/NSTEMI

  • Basically the same, but without the cath lab or fibrinolytics

  • IV, O2, monitor

  • ASA, heparin, ntg, B blocker, morphine

  • Plavix and G IIb/IIIa inhibitors potentially after discussion with cardiology

  • Admit to a monitored unit


Chest pain low risk but risky enough

Chest Pain: low risk, but risky enough

  • Patients who are low risk with risk factors (silly isn’t it?), chest pain free, and have a normal ecg and enzymes

  • Observation unit for serial cardiac enzymes and ecg

  • Stress test vs. CTA

  • Cardiology consult variable


Questions about acs

Questions about ACS?


Chest pain what is it3

Chest Pain: what is it?

38 y/o female presents with sudden onset of chest pain and shortness of breath shortly after retrieving her bags at the baggage claim from a flight home from Hawaii. She states that it is worse when she takes a deep breath. She also complains of this aching pain in her R leg when walking.


Chest pain what is it4

Chest Pain: What is it?

80 y/o bedridden patient sent from the NH with mental status changes and hemoptysis. She is pleasant during the conversation, but has no idea why she is here. She is actively coughing and appears to have increased work of breathing.

Vitals: HR 110 BP 90/60 RR 28 sPO2 88% RA

Lungs: bibasilar rales with R mid lung rhonchi

PMHx: positive for almost everything (she is 80)


Chest pain what is it5

Chest Pain: What is it?

29 y/o obese white female with history of fibromyalgia and chronic back pain presents with R neck and shoulder pain. She woke-up with it this morning, it is similar but worse than her usual aches. It hurts to move, turn, breathe, and live. She went to work today, but the aching was so bad that she had to come to the ER. Chart review shows that she was here 3 weeks ago for similar pain in her neck and lower back.

Vitals: HR 126 BP 130/90 RR 28 sPO2 90% RA


Pe 2006 stats

PE – 2006 stats

  • Approximately 1 in every 500-1000 EC patients has a PE

  • ECPs correctly diagnose about 50%

  • 10% of EC patients with PE die within 30 days even when PE is promptly diagnosed and treated


Chest pain

RISK FACTORS

Carcinoma

Immobility

Trauma or surgery in the last 4 weeks

Smoking

Estrogen/OCP

Pregnancy/PP

Thrombophilia

Connective Tissue Dz

Prior PE or DVT

Signs and Symptoms

Chest Pain

Dyspnea

Hemoptysis

Splinting

Syncope

HR > 100

Pulse ox < 95%

Unilateral arm or leg swelling

PE


Pe diagnosis

PE - Diagnosis

  • Basic Labs – CBC and Chem 7

  • ? Labs – ck-mb, troponin, PT/PTT

  • D dimer- low risk patients only with low pretest probability

  • CXR

    • exclude other diagnosis – CHF, pna, ptx

    • unilateral basilar atelectasis increases the probability of PE

    • Hamptom’s hump – wedge shaped infarction

    • Westermark’s sign – unilateral lung oligemia


Pe cxr

Hampton’s Hump

Westermark’s Sign

PE - CXR


Pe diagnosis1

PE - Diagnosis

  • Ecg

    • Again to exclude other diagnosis

    • Most common finding is sinus tachycardia

    • T wave inversions v1-v4

    • McGinn-White Pattern – s1q3t3

    • New incomplete or complete RBBB

  • Chest CT – moderate to high risk patients or pre-test probability, positive d-dimer


Pe ecg

PE - ECG


Pe ecg1

PE - ECG


Pe treatment

PE - Treatment

  • Heparin unfractionated 80 u/kg bolus then 18 u/kg/hour

  • LMWH 1 mg/kg SQ q12 hours

  • Coumadin – usually started on the floor

  • IVC filter – for pts who failed anticoagulation or have contraindications

  • Thrombolytics – consider in high risk pts such as systolic hypotension, persistent hypoxemia, elevated troponin or BNP (early shock or shock)

  • Surgery – large clot burden, refractory hypotension, floating emboli in the R heart


Pe any questions

PEAny Questions?


Chest pain what is it6

Chest Pain: What is it?

18 y/o tall, thin healthy male c/o sudden onset L sided CP with shortness of breath. The pain started while he was inhaling on a marijuana cigarette. It hurts more to breathe.

Vitals: HR 110 RR 28 BP 110/70 sPO2 96%


Chest pain what is it7

Chest Pain: What is it?

60 y/o male with a history of severe COPD c/o increasing shortness of today that is not relieved with his home inhalers.

Vitals: HR 110 RR 28 BP 110/70 sPO2 90%

Heart: distant, tachycardic and regular

Lungs: diffuse wheezing, decreased breath sounds on the right


Pneumothorax

Pneumothorax

  • Primary Spontaneous – occurs in people without clinically apparent lung disease

    • 15/100,000 in men, 5/100,000 in women

    • Associated factors = tall, smoking, changes in ambient atmospheric pressure, genetics, MVP, Marfan’s syndrome

    • Disruption of the alveolar-pleural barrier is thought to occur when a bleb or bulla ruptures into the pleural space


Pneumothorax1

Pneumothorax

  • Secondary Spontaneous – occur with known underlying pulmonary disease

    • Three times more common in men

    • Associated with any underlying pulmonary disease including infection, ILD, neoplasms, COPD, asthma, etc…

    • Weakening of the alveolar-pleural barrier occurs secondary to the underlying lung disease either from inflammation or development of bullae


Pneumothorax2

Pneumothorax

  • Iatrogenic

    • Complication of intubation or aggressive BVM, central line placement, or any endoscopic procedure involving the trachea or esophagus

    • Consider in any stable patient with acute deterioration, hypoxia, or increased difficulty with ventilation


Tension pneumothorax

Tension Pneumothorax

  • Positive intrapleural pressure causes compression of the mediastinum and the contralateral lung

  • Pressure exceeding 15 to 20 mm Hg impairs venous return to the heart

  • Leads to cardiovascular collapse if not treated immediately -> this is a clinical diagnosis not a radiographic one!


Pneumothorax clinical presentation

Symptoms

Ipsilateral sharp CP

Dyspnea

Pleuritic pain

Cough

Signs

Sinus tachycardia

Hyperresonance

Decreased breath sounds

Unilateral enlargement of the hemithorax

Splinting

Hypoxia

PneumothoraxClinical Presentation


Pneumothorax diagnosis

Pneumothorax: Diagnosis

  • Clinically for tension PTX

  • CXR

    • Radiolucent band devoid of lung markings

    • Inspiratory/expiratory views

    • Lateral decubitus views in sick patients

    • Supine CXR may have deep sulcus sign

  • Thoracic Ultrasound

  • Chest CT


Pneumothorax3

Pneumothorax


Pneumothorax tension

Pneumothorax - Tension


Pneumothorax deep sulcus sign

Pneumothorax – Deep Sulcus Sign


Pneumothorax management

Pneumothorax: Management

  • Tension – needle decompression

  • Tube thoracostomy –> 20-28 F for air, 32F at least if fluid is present

  • Observation – for PTX < 20% collapse

  • Reabsorption Rate

    • 1-2% per day

    • 4-8% if on 100% NRB


Pneumothorax any questions

Pneumothorax – any questions?


Chest pain what is it8

Chest Pain: what is it?

60 y/o male complains of sudden onset tearing chest pain that went up into his jaw, through to his back, and then down into his abdomen. He also vomited once, is diaphoretic, and appears very anxious.

Vitals: BP 190/120 HR 110 RR 22 sPO2 95%


Aortic dissection

Aortic Dissection

  • Occurs more often in men older than 40

  • HTN is the most common risk factor

  • Associated with cardiac surgery, bicuspid aortic valve, stimulant use, and trauma

  • Age<40, associated with congenital heart disease, Marfan, Ehlers-Danlos, and giant cell arteritis

  • 44% of pts with Marfan’s will develop an aortic dissection


Aortic dissection1

Aortic Dissection

  • Type A – 62% of dissections

    • Involve the ascending aorta and are therefore much more lethal

  • Type B – 38% of dissections

    • Do not involve the ascending aorta

    • Pt more likely to be older, smoke, have chronic lung disease, HTN, or atherosclerosis


Aortic dissection diagnosis

Aortic Dissection - Diagnosis

  • Labs - CBC, chem7, PT/PTT, type and cross, CK-MB, troponin

  • ECG- exclude other dx, 15% may have ischemic changes -> 3% dissect back and most commonly involve the RCA, may have LVH or nonspecific ST or T wave changes

  • CXR – abnormal in 80% but nonspecific findings

  • CT scan – test of choice

  • TEE – limited by availability and operator

  • Aortography – no longer the test of choice

  • MRI- excellent test but limited by availability and instability of the patient


Aortic dissection management

Aortic Dissection - Management

  • Opioids – decrease pain and sympathetic tone

  • B blockers – esmolol and labetalol

    • decrease BP and HR to decrease shearing forces

    • Should be started first unless the pt is bradycardic

  • Nipride – vasodilator, used in conjunction with a B blocker to maintain SBP 100-120

  • Hypotensive pts – measure BP in all 4 extremities to make sure it is real, IVF/Blood, immediately to OR

  • Type A -> OR (27% mortality if treated surgically vs 56% if treated medically)

  • Type B uncomplicated – 10% mortality when treated medically (32% mortality if complicated)


Aortic dissection any questions

Aortic Dissection – Any Questions?


Chest pain what is it9

Chest Pain – What is it?

22 y/o healthy male complains of chest and back pain after forcing himself to vomit. He states he had food stuck in his chest while eating at Mongolian BBQ and then forced himself to vomit for relief. He now says that his voice is hoarse, it hurts to breathe deep, and he is still very nauseated. He tried to drink some water, but this only intensified the pain.

Vitals: HR 120 BP 130/90 RR 25 sPO2 97%


Esophageal rupture boerhaave s

Esophageal Rupture – Boerhaave’s

  • 15% are spontaneous with the remainder being iatrogenic from endoscopy, NGT, ETT, combitube, foreign body…

  • 90% of spontaneous ruptures occur in the distal esophagus

  • DX - CXR, gastrograffin swallow, CT

  • Management

    • IV antibiotics

    • NPO and likely NGT

    • Surgery consult


That was the short and sweet of it any questions

That was the short and sweet of it, any questions?


Chest pain what is it10

Chest Pain – What is it?

26 y/o male c/o retrosternal, sharp CP, difficulty breathing, pain when breathing deeply, and worsening dyspnea tonight when he laid down to sleep. He states that for the last week he has had URI symptoms and low grade fever, but now feels that it has moved into his chest with the increasing pain and difficulty breathing.

Vitals: HR 110 BP 110/80 RR 24 sPO2 98%

Heart: tachycardic and regular, (+) pericardial rub

Lungs: CTA B

Bedside TTE is negative for effusion


Pericarditis

Pericarditis


Pericarditis1

Pericarditis

  • Causes – infectious, injury/trauma, metabolic, systemic (RA), carcinoma, or aortic dissection

  • DX – clinical suspicion, ecg, echo

  • Echo – pericardial effusion and tamponade are worrisome complications -> pts should be put in obs or hospitalized

  • Treatment – NSAIDS, steroids for pts who cannot tolerate NSAIDS


The end any questions

THE END!ANY QUESTIONS?


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