1 / 28

Approach to Chest Pain

Approach to chest pain in ETD setting.

drzhafir
Download Presentation

Approach to Chest Pain

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Approach to Chest Pain In Emergency Department Presenter: Dr Ahmad Zhafir bin Zulkfli@Zulkifli Supervisor: Dr Wan Maslizabinti Wan MohdAnuar 31 October 2018

  2. Introduction • Chest pain accounts for a large number of ED visits • Patients present with a spectrum of signs and symptoms reflecting the many potential etiologies of chest pain • Diseases of the heart, aorta, lungs, esophagus, stomach, mediastinum, pleura, and abdominal viscera may all cause chest discomfort • Clinicians in the ED focus on the immediate recognition and exclusion of life-threatening causes of chest pain • Patients with life threatening etiologies for chest pain may appear deceptively well, manifesting neither vital sign nor physical examination abnormalities

  3. Differential • Cardiac • MI • Pericarditis • Myocarditis • Pulmonary • PE • Asthma/COPD • Pleura • Pleuritis • Pneumothorax • Aorta • Dissection • Chest wall • Costochondiritis/musculoskeletal pain • Esophagus • Esophageal Spasm • Esophagitis • Esophageal Rupture/Perforation • GERD • Panic attack

  4. Cayley 2005

  5. Pearl: ALWAYS have the patient point to the pain!

  6. Characterized as discomfort/pressure rather than pain Time duration >2 mins Provoked by activity/exercise Radiation (i.e. arms, jaw) Does not change with respiration/position Associated with diaphoresis/nausea Relieved by rest/nitroglycerin Typical vs. Atypical Chest Pain Typical Atypical Pain that can be localized with one finger Constant pain lasting for days Fleeting pains lasting for a few seconds Pain reproduced by movement/palpation

  7. Typical vs. Atypical Chest Pain UpToDate

  8. Typical vs. Atypical Chest Pain Cayley 2005

  9. Life threatening conditions • Acute coronary syndrome • Acute aortic dissection • Pulmonary embolism • Tension pneumothorax • Pericardial tamponade • Mediastinitis

  10. ACS – STEMI/NSTEMI/USA • Result from atherosclerotic plaque rupture and thrombus formation • DEGREE and DURATION determine whether the patient develops reversible myocardial ischemia without injury (unstable angina) or myocardial ischemia with injury (myocardial infarction)

  11. Pulmonary embolism • Estimated incidence over 1 in 1000 patients, but diagnosis is often missed • Occurs when a dislodged venous clot migrates through the right side of the heart and lodged at the branch point of the pulmonary arteries • Results in pulmonary hypertension, right ventricular dysfunction, poor gas exchange, and ultimately parenchymal infarction • Mortality rates vary widely based upon comorbid conditions and the size of the embolus • Early diagnosis and treatment reduce mortality for large hemodynamically unstable pulmonary emboli

  12. Pneumothorax • Occurs following trauma, pulmonary procedures or spontaneously • Primary vs secondary pneumothorax • Regardless of etiology, the accumulation of air in the pleural space can lead to tension pneumothorax causing rapid clinical deterioration and death if unrecognized

  13. Acute aortic dissection • Incidence of aortic dissection is estimated at 3 per 100,000 patients per year • Elderly, hypertensive patient younger patient in connective tissue disease • Results from tear in the inner layer of the aortic wall allowing blood to track between the intima and media

  14. History • Onset of pain (eg, abrupt or gradual) • Provocation/Palliation (which activities provoke pain; which alleviate pain) • Quality of pain (eg, sharp, squeezing, pleuritic) • Radiation (eg, shoulder, jaw, back) • Site of pain (eg, substernal, chest wall, back, diffuse, localized) • Timing (eg, constant or episodic, duration of episodes, when pain began) • Associated symptoms: diaphoresis, nausea, and vomiting • Risk factors • Elderly >> atypical presentation!

  15. Physical Examination • Most often the physical examination is not helpful in distinguishing patients with acute coronary syndromes (ACS) from those with noncardiac chest pain • Chest pain associated with focal wheezing or asymmetric extremity swelling raises concern for pulmonary embolus (PE) • Unilateral decreased breath sounds may be noted with pneumothorax • The presence of rales is associated with left ventricular dysfunction and left-sided heart failure • Pericardial friction rub in patients with pericarditis

  16. Investigations • 12 leads ECG – AHA suggestion ECG obtained and interpreted within 10 minutes of patient presentation at ED • Serial ECG - increase the sensitivity for detecting ACS • Troponin I and T elevations within 3 hours, peak at 12 hours, and remain elevated for 7 to 10 days • FBC • CXR • Bedside ultrasound

  17. Management • Evaluation of the chest pain patient in ED begins with assessment and stabilization of the airway, breathing, and circulation • Life-threatening problems are treated immediately, without delay for confirmatory testing • Patient is placed on a cardiac monitor and given supplemental oxygen if necessary while intravenous access is established • Obtain bloods, ECG and CXR

  18. Management • Patients with ST elevation myocardial infarction (STEMI) require emergent revascularization via percutaneous intervention or fibrinolysis • Emergent treatment for a suspected aortic dissection involves blood pressure and heart rate control to reduce shearing forces and intensity of pulsatile cardiac flow • Tension pneumothorax is treated with immediate tube thoracostomy or immediate needle thoracostomyfollowed by tube thoracostomy • Patients with stable angina do not require inpatient evaluation

  19. UpToDate

  20. TIMI.ORG

  21. Case Discussion • 64 year old Malay male with underlying DM, HPT presents to ED HoSHAS with 5 hours of left sided chest discomfort associated with SOB, nausea and profuse sweating. Gradual onset while chopping trees in his estate. Partially improved with rest. • On examination:alert, conscious, pink, not tachypnic, warm peripheries, regular pulse volume, CRT <2S, profuse sweating • T 37.5ºC, BP 160/95mmHg, RR16bpm, PR 100bpm, spO2 98% under room air • Lungs clear, equal air entry • CVS s1s2 no murmur • Abdomen soft non tender • No calf tenderness, no pedal edema

  22. ECG

  23. CXR

  24. Diagnosis: • If primary PCI cannot be performed, then fibrinolytic therapy should be administered with a DNT of less than 30 minutes

  25. CPG 2014

  26. References • Cayley, W.E. Diagnosing the cause of chest pain. (2005). American Family Physician, Vol 72 (10), 2012-21 • Malaysian Clinical Practice Guideline on STEMI 3rd edition (2014), MoH • Evaluation of chest pain in the emergency department. UpToDate • Approach to patients with chest pain: differential diagnoses, evaluation and management, ECGWaves.com

  27. Thank you

More Related