Chest pain on the acute medical take acute block uhcw september 25 th 2014
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Chest Pain On The Acute Medical Take Acute Block UHCW September 25 th 2014. Dr. Adam Iqbal Clinical Teaching Fellow UHCW NHS Trust. Objectives. By the end of this session you should be able to: List the common and serious causes of chest pain presenting to the acute medical take

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Chest Pain On The Acute Medical Take Acute Block UHCW September 25 th 2014

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Chest pain on the acute medical take acute block uhcw september 25 th 2014

Chest Pain On The Acute Medical TakeAcute Block UHCWSeptember 25th 2014

Dr. Adam Iqbal

Clinical Teaching Fellow

UHCW NHS Trust


Objectives

Objectives

By the end of this session you should be able to:

List the common and serious causes of chest pain presenting to the acute medical take

Recognise the clinical features of (interactive discussion):

Acute coronary syndrome, aortic dissection, pericarditis

Pulmonary embolism, pneumothorax

Exacerbation of COPD & acute asthma

Recognise radiological features of:

Pericardial effusion

Pneumothorax

Pulmonary embolism

Discuss management of acute coronary syndromes (didactic teaching)


Clinical assessment

A

B

C

D

E

1. IDENTIFY problem

2. CORRECT abnormalities

…then PROCEED

History:

SQITAS

Problem solving

PMHx

DA

SHx, FHx

Clinical Assessment

Which system?

Cardiac

Respiratory Musculoskeletal

Gastrointestinal Neurological


Clinical features of acs

HISTORY

CLINICAL EXAMINATION

Clinical Features of ACS …


Clinical features of acs1

HISTORY

Sudden onset central chest pain

“Squeezing, tight, crushing, pressure, dull ache”

Radiation – neck, jaw, arms

Typically severe (subjective!)

Precipitated by exertion, relieved by rest (but beware unstable disease)

Sweaty, nauseous, collapse

DM, smoker, IHD, male, age, FHx, alcohol, HTN, PVD, renal failure

(Beware atypical presentation in women, DM, elderly)

CLINICAL EXAMINATION

Usually normal unless complications

May be some evidence of risk factors: PVD (i.e. bypasses, tissue loss), DM (fingerprick), tar staining, hypertensive changes (retinal, bruits), arcus

Clinical Features of ACS …


Clinical features of aortic dissection

HISTORY

CLINICAL EXAMINATION

Clinical Features of Aortic Dissection


Clinical features of aortic dissection1

HISTORY

Sudden onset severe central chest pain

“Tearing”

Radiation – arms, back

May ‘migrate’

Neurological symptoms

Autoimmune rheumatic disorders, Ehlers-Danlos, Marfan’s, HTN, trauma, recent instrumentation of aorta

CLINICAL EXAMINATION

Tachycardic, raised BP

Brachial pulse discrepancy

Proximal extension:

murmur (AR), cardiac tamponade/ischaemia

Distal extension:

renal failure, visceral, limb, or spinal ischaemia

Clinical Features of Aortic Dissection


Clinical features of pericarditis

HISTORY

CLINICAL EXAMINATION

Clinical Features of Pericarditis


Clinical features of pericarditis1

HISTORY

Sharp central chest pain

Worsened by movement, breathing, and lying down (relieved by sitting forwards)

Hx of recent cardiothoracic insult (surgery, radiotx, trauma) or MI (AMI, Dressler’s)

Recent viral, bacterial, tuberculous illness

CLINICAL EXAMINATION

Pericardial rub

Features of pericardial effusion

Haemodynamic compromise

Features of acute heart failure (myocarditis or constrictive pericarditis)

Clinical Features of Pericarditis


Clinical features of pulmonary embolism

HISTORY

CLINICAL EXAMINATION

Clinical Features of Pulmonary Embolism

PEs can be small, massive, or multiple


Clinical features of pulmonary embolism1

HISTORY

Dyspnoea (chronic or sudden onset)

Chest pain (+/- pleuritic)

Cough (+/- haemoptysis)

Risk factors: prev VTE, smoker, pregnancy, immobility, recent surgery, dehydrated, FHx VTE, drugs, OCP

CLINICAL EXAMINATION

Tachypnoea, tachycardia

Raised JVP, hypotension

Features of pulm HTN

Minimal chest signs

Peripheral DVT

Clinical Features of Pulmonary Embolism

PEs can be small, massive, or multiple


Clinical features of pneumothorax

HISTORY

CLINICAL EXAMINATION

Clinical Features of Pneumothorax


Clinical features of pneumothorax1

HISTORY

Sudden onset unilateral pleuritic chest pain or progressively increasing breathlessness

Cough

Young male (M:F ratio 6:1), tall, COPD, asthma, ca lung, suppurative lung disease, instrumentation (!!)

CLINICAL EXAMINATION

Tachypnoea, desaturation

Haemodynamic compromise if tension

Reduced expansion, tympanic PN

Mediastinal shift

Clinical Features of Pneumothorax


Clinical features of copd exacerbation

HISTORY

CLINICAL EXAMINATION

Clinical Features of COPD Exacerbation


Clinical features of copd exacerbation1

HISTORY

Cough, Phlegm, Fever

Chest pain (tightness, sharp/pleuritic)

SOB, wheeze

Smoker, known obstructive spirometry, under resp physician, frequent exacerbations

CLINICAL EXAMINATION

Tar staining, CO2 flap, tachypnoea, tachycardia, cyanosis, hyperexpanded chest, accessory muscle use, resonant PN, crackles, bronchial sounds, wheeze, prolonged expiratory phase

Clinical Features of COPD Exacerbation


Clinical features of acute asthma

HISTORY

CLINICAL EXAMINATION

Clinical Features of Acute Asthma


Clinical features of acute asthma1

HISTORY

SOB

Cough

Wheeze

Phlegm

(Diurnal variation, triggers)

Hx of atopy

DA: beta-blockers, NSAIDs

CLINICAL EXAMINATION

Tachypnoea, tachycardia

Widespread wheeze

Accessory muscle use

Desaturation, cyanosis, see-sawing

Clinical Features of Acute Asthma


Acute coronary syndrome

Acute Coronary Syndrome

  • Make the diagnosis !

  • Manage cause / condition / complications

ACS

Angina UANSTEMI STEMI


Pathophysiology

Pathophysiology


Angina unstable angina

Angina Unstable Angina

Exertional

Relieved by rest

± ECG changes ( ST depression, T wave inversion)

Troponin negative

Can occur at rest

Crescendo

± ECG changes ( ST depression, T wave inversion)

Troponin negative


Nstemi stemi

NSTEMISTEMI

Troponin +ve

± ECG changes (ST depression/ T wave inversion)

Troponin +ve

ST elevation

2mm in 2 consecutive chest leads

1mm in 2 limb leads

New onset LBBB


Acute management of acs

Acute Management of ACS

  • A-E assessment (ECG vital)

  • Identify Problem > Correct > Reassess > Proceed

  • Monitoring (!!)

  • UA / NSTEMI

    • Aspirin 300mg, Clopidogrel 300mg, Clexane 1mg/kg SC BD

  • STEMI

    • 2222 (!!)

    • Aspirin 300mg, Ticagrelor 180mg

  • Manage symptoms / complications

    • Beta-blockers prevent arrhythmias (!!)

    • GTN (SL or infusion)

    • Analgesia (diamorphine 2.5-10mg IV) & Antiemetic (metoclopramide 10mg IV)

    • Careful clinical assessment (arrhythmias, heart failure, RVF etc)

    • Oxygen ONLY IF HYPOXIC


Chest pain on the acute medical take acute block uhcw september 25 th 2014

  • ABSOLUTE CONTRAINDICATIONS

  • Active bleeding or GI bleed < 4/52

  • Suspected aortic dissection

  • Surgery/Trauma/Head injury < 2/52

  • Recent non-embolic stroke <6/12

  • RELATIVE CONTRAINDICATIONS

  • HTN

  • Prolonged CPR (>5min)

  • Pregnancy

  • Therapeutic anticoagulation

  • Retinopathy


Investigations

Investigations

Electrocardiogram – serial

Blood tests

Full Blood Count / U&E

Lipid Profile / BMs

Clotting screen

Troponin (in this trust 3hrs & 6hrs)

Chest radiograph

Echocardiogram (LV function)

Coronary angiogram > PCI

Myocardial perfusion scan


Post event management

Post Event management

Lifestyle & risk factor modification

Smoking cessation

Dietary changes

Exercise

Diabetes & dyslipidaemia

HTN

Secondary prevention

ACE-I

Beta-Blocker

Statins

Dual anti-platelet therapy for 1yr, aspirin for life

Cardiac rehabilitation

Clinic follow up & repeat echocardiography


Summary

Summary

  • Chest pain is the single most common presenting complaint on the acute take

  • Know how to recognise the serious (& rare!)

  • Reassure the patient

  • Bear in mind causes not discussed here i.e. GI

  • Apply your clinical reasoning (as opposed to questioning by rote) & you will recognise what you have never seen

  • Be thorough, systematic, logical and … keep an open mind!


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