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APPROACH TO CHEST PAIN. DR. PRAKASH MOHANASUNDARAM EMERGENCY PHYSICIAN Department of Accident, Emergency & Critical Care Medicine. Vinayaka Mission Kirupananda Variyar Medical college Hospital, Salem, Tamilnadu, India . www.emergencymedicineindia.com. BACKGROUND.

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approach to chest pain

APPROACH TO CHEST PAIN

DR. PRAKASH MOHANASUNDARAM

EMERGENCY PHYSICIAN

Department of Accident, Emergency & Critical Care Medicine.

Vinayaka Mission Kirupananda Variyar Medical college Hospital,

Salem, Tamilnadu, India.

www.emergencymedicineindia.com

background
BACKGROUND
  • Approx 5% of all ED visits
  • 15% - AMI
  • 25-30% - Unstable angina
  • 14 -34% - Other conditions
  • Atypical presentations – common
acute chest pain
ACUTE CHEST PAIN
  • Recent onset, typically less than 24 h
  • Location described on the anterior thorax
  • A noxious uncomfortable sensation distressing to the patient.
categorisation
CATEGORISATION
  • Visceral pain
  • Pleuritic pain
  • Chest wall pain
visceral pain

Typical exertional angina

Atypical angina

Unstable angina

Acute myocardial infarction

Aortic dissection

Pericarditis

Oesophageal reflux or spasm

Oesophageal rupture

Mitral valve prolapse

VISCERAL PAIN
pleuritic pain

Pulmonary embolism

Pneumonia

Spontaneous pneumothorax

Pericarditis

Pleurisy

PLEURITIC PAIN
chest wall pain

Costosternal syndrome

Costochondritis

Precordial catch syndrome

Slipping rib syndrome

Xiphodynia

Radicular syndromes

Intercostal nerve syndromes

Fibromyalgia

CHEST WALL PAIN
slide8

Etiology

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Quality

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Location

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Radiation

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Asso.Symptoms

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Onset

Onset

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Onset

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Onset

Onset

Onset

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Onset

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Onset

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Onset

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MI

MI

MI

MI

MI

MI

MI

MI

MI

MI

MI

MI

MI

MI

MI

MI

MI

MI

MI

MI

MI

MI

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MI

MI

MI

MI

MI

MI

MI

visceral

visceral

visceral

visceral

visceral

visceral

visceral

visceral

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retrosternal

retrosternal

retrosternal

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retrosternal

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retrosternal

retrosternal

Neck

jaw shoulder arm

Neck

jaw shoulder arm

Neck

jaw shoulder arm

Neck

jaw shoulder arm

Neck

jaw shoulder arm

Neck

jaw shoulder arm

Neck

jaw shoulder arm

Neck

jaw shoulder arm

Neck

jaw shoulder arm

Neck

jaw shoulder arm

Neck

jaw shoulder arm

Neck

jaw shoulder arm

Neck

jaw shoulder arm

Neck

jaw shoulder arm

Neck

jaw shoulder arm

Neck

jaw shoulder arm

Neck

jaw shoulder arm

Neck

jaw shoulder arm

Neck

jaw shoulder arm

Neck

jaw shoulder arm

Neck

jaw shoulder arm

Neck

jaw shoulder arm

Neck

jaw shoulder arm

Neck

jaw shoulder arm

Neck

jaw shoulder arm

Neck

jaw shoulder arm

Neck

jaw shoulder arm

Neck

jaw shoulder arm

Neck

jaw shoulder arm

Neck

jaw shoulder arm

>15 min

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Nausea, vomiting, diaphoresis, dyspnoea

Nausea, vomiting, diaphoresis, dyspnoea

Nausea, vomiting, diaphoresis, dyspnoea

Nausea, vomiting, diaphoresis, dyspnoea

Nausea, vomiting, diaphoresis, dyspnoea

Nausea, vomiting, diaphoresis, dyspnoea

Nausea, vomiting, diaphoresis, dyspnoea

Nausea, vomiting, diaphoresis, dyspnoea

Nausea, vomiting, diaphoresis, dyspnoea

Nausea, vomiting, diaphoresis, dyspnoea

Nausea, vomiting, diaphoresis, dyspnoea

Nausea, vomiting, diaphoresis, dyspnoea

Nausea, vomiting, diaphoresis, dyspnoea

Nausea, vomiting, diaphoresis, dyspnoea

Nausea, vomiting, diaphoresis, dyspnoea

Nausea, vomiting, diaphoresis, dyspnoea

Nausea, vomiting, diaphoresis, dyspnoea

Nausea, vomiting, diaphoresis, dyspnoea

Nausea, vomiting, diaphoresis, dyspnoea

Nausea, vomiting, diaphoresis, dyspnoea

Nausea, vomiting, diaphoresis, dyspnoea

Nausea, vomiting, diaphoresis, dyspnoea

Nausea, vomiting, diaphoresis, dyspnoea

Nausea, vomiting, diaphoresis, dyspnoea

Nausea, vomiting, diaphoresis, dyspnoea

Nausea, vomiting, diaphoresis, dyspnoea

Nausea, vomiting, diaphoresis, dyspnoea

Nausea, vomiting, diaphoresis, dyspnoea

Nausea, vomiting, diaphoresis, dyspnoea

Nausea, vomiting, diaphoresis, dyspnoea

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angina

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angina

angina

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angina

Angina

angina

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visceral

visceral

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retrosternal

Neck,

Jaw

shoulder,

arm

Neck,

Jaw

shoulder,

arm

Neck,

Jaw

shoulder,

arm

Neck,

Jaw

shoulder,

arm

Neck,

Jaw

shoulder,

arm

Neck,

Jaw

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arm

Neck,

Jaw

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arm

Neck,

Jaw

shoulder,

arm

Neck,

Jaw

shoulder,

arm

Neck,

Jaw

shoulder,

arm

Neck,

Jaw

shoulder,

arm

Neck,

Jaw

shoulder,

arm

Neck,

Jaw

shoulder,

arm

Neck,

Jaw

shoulder,

arm

Neck,

Jaw

shoulder,

arm

Neck,

Jaw

shoulder,

arm

Neck,

Jaw

shoulder,

arm

Neck,

Jaw

shoulder,

arm

Neck,

Jaw

shoulder,

arm

Neck,

Jaw

shoulder,

arm

Neck,

Jaw

shoulder,

arm

Neck,

Jaw

shoulder,

arm

Neck,

Jaw

shoulder,

arm

Neck,

Jaw

shoulder,

arm

Neck,

Jaw

shoulder,

arm

Neck,

Jaw

shoulder,

arm

Neck,

Jaw

shoulder,

arm

Neck,

Jaw

shoulder,

arm

Neck,

Jaw

shoulder,

arm

Neck,

Jaw

shoulder,

arm

<15 min

<15 min

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Nausea, vomiting,

diaphoresis,

dyspnoea

Nausea, vomiting,

diaphoresis,

dyspnoea

Nausea, vomiting,

diaphoresis,

dyspnoea

Nausea, vomiting,

diaphoresis,

dyspnoea

Nausea, vomiting,

diaphoresis,

dyspnoea

Nausea, vomiting,

diaphoresis,

dyspnoea

Nausea, vomiting,

diaphoresis,

dyspnoea

Nausea, vomiting,

diaphoresis,

dyspnoea

Nausea, vomiting,

diaphoresis,

dyspnoea

Nausea, vomiting,

diaphoresis,

dyspnoea

Nausea, vomiting,

diaphoresis,

dyspnoea

Nausea, vomiting,

diaphoresis,

dyspnoea

Nausea, vomiting,

diaphoresis,

dyspnoea

Nausea, vomiting,

diaphoresis,

dyspnoea

Nausea, vomiting,

diaphoresis,

dyspnoea

Nausea, vomiting,

diaphoresis,

dyspnoea

Nausea, vomiting,

diaphoresis,

dyspnoea

Nausea, vomiting,

diaphoresis,

dyspnoea

Nausea, vomiting,

diaphoresis,

dyspnoea

Nausea, vomiting,

diaphoresis,

dyspnoea

Nausea, vomiting,

diaphoresis,

dyspnoea

Nausea, vomiting,

diaphoresis,

dyspnoea

Nausea, vomiting,

diaphoresis,

dyspnoea

Nausea, vomiting,

diaphoresis,

dyspnoea

Nausea, vomiting,

diaphoresis,

dyspnoea

Nausea, vomiting,

diaphoresis,

dyspnoea

Nausea, vomiting,

diaphoresis,

dyspnoea

Nausea, vomiting,

diaphoresis,

dyspnoea

Nausea, vomiting,

diaphoresis,

dyspnoea

Nausea, vomiting,

diaphoresis,

dyspnoea

gradual

gradual

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slide9

Etiology

Quality

Location

Radiation

Duration

Asso. Symptoms

Onset

Aortic dissection

severe

retrosternal

Inter scapular tearing

constant

Nausea diaphoresis,

dyspnoea

Sudden

PE

pleuritic

lateral

constant

dyspnoea

sudden

Pneumothorax

pleuritic

lateral

Neck, back

constant

dyspnoea

sudden

scenario 1
SCENARIO - 1
  • 40 year old gentleman comes to ER with h/o chest pain, breathlessness, sweating since 2 hrs
  • Chest pain retrosternal, crushing type, non radiating lasting for 2 hrs
  • H/O hypertension for the past 3 years,
  • Known smoker and a genetic h/o heart disease.
vitals
BP-110/60

HR-104

RR-34

SPO2-95%

CVS – Tachycardia

RS - Tachypnoea

PA - Soft

CNS- NFND

VITALS
immediate assessment 10 min
Immediate Assessment (<10 min)

Cardiac marker levels

Electrolytes

Coagulation studies

Vital signs / O2 sat

IV Access

ABC

Brief history

Fibrinolytic checklist

Physical examination

12 Lead ECG

CXR (EARLY)

immediate general treatment
Immediate General Treatment

ONAM

OXYGEN

NITRATES

MORPHINE

ASPIRIN

assess initial 12 lead ecg
Assess Initial 12-Lead ECG
  • Classify patients with acute ischemic chest paininto 1 of 3 ECG classification groups:
    • STEMI
    • NSTEMI / UA
    • Nondiagnostic or Normal
slide17
….ECG

STEMI

ST elevation / presumed new LBBB 0.1mv or 1mm in 2 or more contiguous precordial leads or 2 or more adjacent limb leads.

UA/NSTEMI

ST dep ≥ 0.5 mm (0.05mv) or dynamic T inversions with pain or discomfort

Non-persistent or transient ST elevation >0.5mm for less than 20 mins

Nondiagnostic

ST deviation <0.5 mm or T inversions <0.2 mm

slide18

“ J “ POINT

J point plus

0.04 second

ST-segment deviation= 4.5 mm

PP baseline

The point at which the ST segment originates

from the QRS complex is called the J point

how to identify lbbb
How to identify LBBB
  • Deep S wave in V1 and

a tall late R wave in

lead I and/or V6,wide QRS complexes

  • WILLIAM
  • Serial Cardiac markers for confirmation
slide22

AMI Localization

I lateral

aVR

V1 septal

V4 anterior

II inferior

aVL lateral

V2 septal

V5 lateral

V6 lateral

III inferior

aVF inferior

V3 anterior

cardiac markers
CARDIAC MARKERS

Limited role in case of diagnostic ST elevation in ECG

Role in pts with nondiagnostic ECG changes

Early diagnosis

Missed MI

Early risk stratification

Requires Serial Measurements rather than single (every 2-3 hours)

cardiac markers29
…CARDIAC MARKERS

CK :

Levels twice upper limit of normal = abnormal

Rises within 4-8hrs & falls within 3-4 days

False + results

CK-MB isoenzyme:

More specific

False +

AST : rise 18-36hrs post MI

LDH : rise 24-36hrs post MI

cardiac markers30
…CARDIAC MARKERS

TROPONINS

TnI more sensitive and specific in serial testing & not at presentation.

Starts to rise by 6 hrs & persists upto 7-10 days. (diagnose late MI)

Also elevated in myocarditis ,CM & pericarditis

diagnostic criteria any two out of three
DIAGNOSTIC CRITERIA(ANY TWO OUT OF THREE)
  • Typical history
  • ECG changes
  • Cardiac enzyme elevation

CK

CKMB

TROPONIN

goals of treatment
Goals of treatment
  • Door to needle time < 30 mins (thrombolysis)
  • Door to balloon time < 90 mins (reperfusion)
scenario 2
SCENARIO - 2
  • A 40 year male, brought to ER with h/o sudden onset chest pain & breathlessness since 2 hrs.
  • Pleuritic pain, constant over the anterior thorax
  • Has travelled from USA to INDIA 3 hrs back
  • Chronic smoker
vitals35
BP-100/60;

HR-146;

RR-42;

SPO2-88%

TROPONIN I – not raised

CVS- tachycardia

RS – tachypnoea

PA – soft

CNS - NFND

VITALS
pulmonary embolism
PULMONARY EMBOLISM

Pulmonary embolism (PE) is a blockage of the pulmonary artery or one of its branches,

usually occuring when a venous thrombus becomes dislodged from its site of formation and

embolizes to the arterial blood supply of one of the lungs.

facts
FACTS
  • > 50 % pts with DVT are associated with PE
  • > 50 % cases do not have any signs or symptoms
  • Common presentation can be unexplained tachycardia, tachypnoea, hypoxemia or mere anxiety
  • Diagnosis and suspicion is purely clinical
clinical features
Clinical Features

Symptoms in Patients with Angio Proven PTE

Symptom Percent

Dyspnea 84

Chest Pain, pleuritic 74

Anxiety 59

Cough 53

Hemoptysis 30

Sweating 27

Chest Pain, nonpleuritic 14

Syncope 13

clinical features41
Clinical Features

Signs with Angiographically Proven PE

Sign Percent

Tachypnea > 20/min 92

Rales 58

Accentuated S2 53

Tachycardia >100/min 44

Fever > 37.8 43

Diaphoresis 36

S3 or S4 gallop 34

Thrombophebitis 32

Lower extremity edema 24

slide42
ECG

Most Common Findings:

Tachycardia or nonspecific ST/T-wave changes

Acute cor pulmonale or right strain patterns

Tall peaked T-waves in lead II (P pulmonale)

Right axis deviation

RBBB

S1-Q3-T3 (occurs in only 20% of PE patients)

Atrial fibrillation / Atrial flutter

chest x ray
Chest X ray

Westermark’s sign

focal oligemia / cut off sign

Hampton’s hump

peripheral wedge shaped density above the diaphragm

Palla’s sign

enlarged right descending pulmonary artery

ALMOST ALWAYS NORMAL CHEST X-RAY

slide44

WESTERMARK’S SIGN

HAMPTON’S HUMP

PALLA’S SIGN

ALMOST ALWAYS NORMAL CHEST X-RAY

pulmonary angiography gold standard
Pulmonary Angiography (GOLD STANDARD)

Arrow indicates abrupt termination of a pulmonary artery.

Www.brighamrad.Harvard.edu/cases/bwh/images.

heparin lmwh warfarin
Heparin / LMWH / Warfarin
  • Heparin

80 U/kg iv bolus foll by 18 U/kg/hr

  • Enoxaparin

1 mg/kg twice daily / 1.5 mg/kg daily

  • Tinzaparin

175 mg/kg OD

  • Fondaparinux

<50 kg receive 5 mg,

50–100 kg patients receive 7.5 mg

>100 kg receive 10 mg.

  • Warfarin – 2.5 to 10 mg

Target INR – 2.0 TO 3.0

thrombolysis
THROMBOLYSIS
  • Recombinant tPA

100 mg iv infusion over 2 hours

  • Streptokinase

250,000 U iv over 30 mins foll by

100,000 U/hr for 24 hrs

  • Urokinase

4,4OO U/kg iv over 10 mins foll by

4,000 U/kg/hr for 12 hrs

  • Alteplase

15 mg iv bolus foll by 2 hr infusion of 85 mg

( discontinue heparin during infusion)

embolectomy
EMBOLECTOMY

Indicated in pts with risk of thrombolysis

  • Surgical embolectomy
  • Catheter embolectomy
scenario 3
SCENARIO - 3
  • A 30 year man brought to ER with h/o fall from a two wheeler 10 mins back
  • Severe chest pain, breathlessness since then.
  • Chest pain & breathlessness increasing rapidly
  • No external injuries
  • No previous medical illness
  • Occasional smoker
  • What are your DD’s??????????
in er
Sudden altered sensorium

Airway – patent

Breathing

RR- 47/min

Spo2 – 86 >>>>>>65%

shallow respirations

Circulation

BP- 70/30 mmHg

HR- 156/ min

CBG- 126/ min

Absent breath sounds on rt side

Tympanic note on percussion

Heart sounds heard- no muffling

Engorged neck veins

IN ER
slide53

WHAT'S YOUR DIAGNOSIS?

WHAT IS YOUR NEXT STEP?

tension pneumothorax
TENSION PNEUMOTHORAX

CHEST XRAY - ITS A CRIME

needle thoracocentesis56
Needle thoracocentesis
  • Second intercostal space, midclavicular line on the side of the tension pneumothorax.
  • Upper border of lower rib
  • Medially midclavicular line may damage the great vessels, hilar structures and the heart.
  • Under water seal- ICD IS A MUST.
diagnosis
DIAGNOSIS
  • Severe respiratory distress
  • Decreased breath sounds
  • Hyperresonance on percussion
  • Distended neck veins
  • Deviation of trachea to opposite side
scenario 4
A 54 year male brought to ER with altered sensorium within 1 hour

Airway – patent

Breathing – shallow

RR- 40/min

Spo2- 78%

Circulation – BP-80/60

HR – 144/min

CBG – 144

GCS- 7/15

CVS – sinus tachycardia

RS – tachypnoea

crepitus over

mediastinum

PA – distension & rigidity

BS – not heard

SCENARIO - 4
slide61
k/c/o oesophageal stricture for which he underwent an endoscopy
  • Chronic alcoholic & smoker
  • While awaiting his reports he devoloped acute severe chest pain in 10 mins & sensorium deteriorated in another 10 mins
  • He was shifted to our hospital for further management
diagnosis64
Diagnosis
  • Chest X ray
  • CT Chest
  • Emergency endoscopy
slide65
Rx
  • ABC
  • Fluid rescuscitation
  • Broad spectrum parenteral antibiotics
  • Emergent surgical consultation surgical intervention
scenario 5
SCENARIO - 5
  • A 65 year old man comes to the ER with h/o sudden onset of chest pain . He was just about to go out for a meet with his friends
  • He is a K/C/O hypertension, DM for the past 10 years on medications.
  • He is a smoker
slide67

He also c/o inability to move his lower limbs now

  • Hoarseness of voice
  • Dysphagia
  • His femoral pulses are weak when correlated with his radial BP.
  • BP – 80/60
  • HR – 152
  • RR – 32
  • SPO2 – 88%
  • CVS- tachycardia
  • RS – inadequate chest rise
  • PA – soft , BS-sluggish
aortic dissection
AORTIC DISSECTION
  • Typical symptoms-Anterior chest pain,Neck or jaw pain, Interscapular tearing or ripping pain ,
  • Reduced perfusion- Myocardial infarction ,Neurologic symptoms, Syncope, Stroke symptoms ,Altered mental status, Hemiparesis or hemiplegia
  • Symptoms of compression- Horner syndrome, Dyspnoea, Dysphagia ,Orthopnoea, Flank pain, and hemoptysis
investigations
Investigations
  • Angiography is gold standard
  • Aortography-dissection in branch vessels,AV incompetence
  • Contrast problems and arranging the team
  • USG Thorax/ TEE
  • CT –fast with IV contrast.

preferred in unstable

  • No details of branches
slide71
TEE in experienced hands-useful.
  • CXray-thoracic Aorta- widening of mediastinum, abnormal aortic contour, Pl Eff, tracheal deviation,
  • Intimal calcium sign.
management
Management
  • Reduce BP-shearing force- negative inotrope
  • Beta blocker- esmolol, metaprolol
  • Esmolol 500 mic/kg bolus

maint 50-100 mics/kg/min

  • Vasodilator-SNP- 0.3 mic/kg/min IV
  • Immediate surgical referral
  • Surgical exploration
take home message
TAKE HOME MESSAGE
  • Prompt aggressive control of ABC saves > 50% of cases
  • Atypical presentations are common
  • Chances of missed diagnosis is high
  • Approach every chest pain as a life threatening disorder
  • Serial monitoring is required
  • GERD is a diagnosis of exclusion
references
References

Circulation 2005

ACLS Provider 2006

Textbook of emergency medicine; Judith.E.Tintinalli

Harrison’s principles of Internal Medicine;17th Edition

Braunwald’s

Critical Care Book by Edward & Fink

Rosen’s etxt book of emergency medicine

ACC and AHA Guidelines 2006.

Oxford hand book of cardiology.

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