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Acute Chest Pain in Emergency Room

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    1. Acute Chest Pain in Emergency Room Dr Chaitanya Vemuri Post Graduate Student

    2. Introduction Chest Pain Diseases of heart aorta lungs pleura mediastinum oesophagus stomach abdominal viscera musculoskeletal psychological

    3. Approach History Clinical Examination Differential Diagnosis Investigations

    4. History Onset of pain ( abrupt / gradual ) Site of pain (substernal, chest wall, diffuse, localized) Quality of Pain ( squeezing, catching, burning, dull ache ) Radiation ( shoulder, jaw, back ) Provocation / Palliation ( activities that provoke pain or alleviate pain ) Timing ( constant / episodic, duration of episodes )

    5. Clinical examination ECG Chest X ray 2D Echocardiography Special Investigations

    6. Aim in Emergency Room Immediate recognition and exclusion of life-threatening causes of chest pain

    7. Acute Coronary Syndrome Aortic Dissection Pulmonary Embolism Pneumothorax Mediastinitis Pericardial Tamponade

    8. Case 1 A 58 year old male Smoker k/c/o Systemic Hypertension Dyslipidemia Diabetes mellitus type 2 c/o left sided chest pain since last 30 minutes squeezing pain gradual onset radiating to jaw and left arm associated with dyspnea, sweating and vomiting On ex : Pul : 90 / min BP : 150 / 90 mm Hg RR : 20 /min CVS : S1+,S2+, No murmurs RS : Clear

    9. Acute Coronary Syndrome History Left sided or Substernal chest pressure or tightness Onset is gradual Pain radiating to shoulder, jaw Pain increasing on exertion Atypical symptoms dyspnea, weakness in elderly and diabetics

    10. Acute Coronary Syndrome Clinical Examination Nonspecific Signs of Heart failure Acute LVF Bradycardia / Heart block / Hypotension

    11. Acute Coronary Syndrome Investigations ECG Cardiac Enzymes 2D Echocardiogram

    12. Acute coronary syndrome refers to any constellation of clinical symptoms that are compatible with acute myocardial ischemia and encompasses acute myocardial infarction. - STEMI, - NSTEMI, - Unstable Angina

    13. Anterior wall ischemia

    14. Evolution of MI

    15. Acute anterolateral wall ischemia

    16. Acute lateral wall ischemia

    17. Acute myocardial infarction

    18. Acute anterior wall stemi

    19. Acute anteroseptal MI with RBBB

    20. Acute inferior wall MI

    21. Acute inferior wall MI

    22. Posterior wall MI

    23. Cardiac Enzymes In patients with negative cardiac enzymes within 6 hrs of onset of pain , another sample should be drawn within 6 12 hrs Troponin I & Troponin T : Preferred Biomarker Increase in 3-12 hrs after the onset of MI Peak at 24-48 hrs Return to baseline over 5 -14 days

    24. Cardiac Enzymes CK-MB : >95% Sensitivity & Specificity for myocardial injury when measured 24-36 hrs after the onset of chest pain Increase within 3-12 hrs of chest pain Peak at 24 hrs Return to baseline after 48-72 hrs CKMB : CK > 2.5 Suggests myocardial source but not diagnostic

    25. 2D Echocardiogram Look for Regional wall motion abnormality LV function RV function Mitral Regurgitation

    26. Management Oxygen Inhalation Morphine pain relief Antiplatelets Statins Betablockers ACEI /ARB IV/ SC Heparin / Thrombolysis / PCI +/- Diuretics

    28. Case 2 70 year old male k/c/o Systemic Hypertension c/o Sudden onset Chest pain tearing in nature along the back

    29. Aortic Dissection History Sudden onset of sharp, tearing or ripping pain Maximal severity at onset Often begins in chest / can begin in back

    30. Aortic Dissection Clinical Examination Absent upper extremity or carotid pulse Discrepancy in Systolic BP > 20 mm Hg between right and left upper limb Aortic Regurgitation 30 % Neurological findings

    31. Aortic Dissection Investigations ECG : 15 % - Ischemic changes 30 % - Non specific ST T changes CXR : Wide mediastinum / Loss of Normal Aortic Knob Contour 76 % Normal 10 %

    32. Chest X Ray

    33. 2D Echocardiogram

    35. Case 3 A 50 Year old female # neck of femur s/p surgery on prolonged bed rest swelling of left lower limb since 1 week sudden onset dyspnea since 4 hrs associated sharp catchy chest pain on right side On ex : Tachypnea Pulse : 110 / min BP : 110/60 mm Hg Chest : Clear ; CVS : S1+S2+ No murmurs

    36. Pulmonary Embolism The Great Masquerader History Risk Factors : Prolonged Immoblization Deep Vein Thrombosis Malignancy Central Venous Instrumentation<3m Pleuritic chest pain Dyspnea ( dominant feature ) Sudden in onset

    37. Pulmonary Embolism Clinical Examination Symptoms & Signs highly non specific & variable and also common in those with and without PE No finding is specific Extremity may be normal Tachypnea common Tachycardia Jugular venous distension Non specific focal rales Absent breath sounds Loud P2

    38. Pulmonary Embolism Massive Pul Embolism : Acute RV failure Jugular venous distension RV S3 Parasternal Lift Rarely Circulatory Collapse

    39. Pulmonary Embolism Blood Tests : D-dimer : A Useful Rule-out Test Sensitivity > 80% for DVT Sensitivity > 95% for PE Not specific for PE Levels increase in MI,Pneumonia,Sepsis Cardiac Biomarkers : Elevated S.Troponin ( RV microinfarct ) Elevated S.BNP / NT-ProBNP ( myocardial strech )

    40. Pulmonary Embolism ECG : usually abnormal ; nonspecific Sinus Tachycardia S1Q3T3 T wave inversion in V1-V4 Signs of Right heart strain - Right axis deviation - RBBB - Right atrial enlargement

    41. Pulmonary Embolism

    42. Chest X Ray

    43. Chest X Ray

    44. Chest X Ray

    45. Echocardiography Not of diagnostic value Useful to rule out mimics of PE : Acute MI Pericardial Tamponade Aortic Dissection Mc Connells Sign Specific Appearance of RV Hypokinesia of RV free wall with normal motion of RV apex

    46. Diagnostic modalities MDCT Chest with Contrast + Pulmonary angiogram Principal imaging for the diagnosis of PE Ventilation Perfusion Scan 2nd line investigation Pulmonary Angiography Gold standard

    47. CT-PA

    48. Case 4 A 50 year old male k/c/o COPD Emphysema Sudden onset Right Chest Pain Sharp , Catchy With predominant Dyspnea On Ex : Pul 100 /min BP : 110/60mmHg RR: 40/min Deviation of trachea to left side Hyperresonance - Rt side of chest Diminished Breath sounds - Right side of chest

    49. Pneumothorax Can occur Following trauma Following pulmonary procedures Primary Spontaneous pneumothorax Secondary pneumothorax COPD - Asthma - Cystic Fibrosis

    50. History Sudden onset pleuritic chest pain Dyspnea as dominant feature Clinical Examination Tachypnea Shift of mediastinum to contralateral side Ipsilateral diminished or absent breath sounds

    51. Chest X Ray

    52. Case 5 46 year old male c/o Sudden onset diffuse chest discomfort / pain Dyspnea predominantly On ex : Tachypnea Hyperresonance on percussion bilaterally b/l diminished breath sounds

    53. D/D

    54. Case 6 A 30 year old male Alcoholic Post alcohol consumption Devoleped severe retching and vomitings Followed by excruciating retrosternal chest pain Also upper abdominal pain On Ex : Tachypnea Cyanosis Fever Hypotension Shock

    55. Mediastinitis Esophageal Rupture Occurs in Alcoholics Patients with gastric or duodenal ulcer Spontaneous perforation of esophagus after vomiting - Boerhaaves Syndrome Spontaneous esophageal rupture can also occur in : Caustic ingestion Pill esophagitis Baretts ulcer following dilatation of esophageal strictures

    56. Clinical examination Non specific findings early in course of illness Subcutaneous emphysema not specific Hammans crunch mediastinum Pleural effusion

    57. Chest X Ray

    58. CT Chest

    59. Cardiac Tamponade History Sharp anterior chest pain made worse by lying down Pain relieved by sitting forward Pain aggravated by inspiration Dyspnea : common

    60. Clinical examination Sinus tachycardia Elevated JVP ( Preserved X descent Absent Y descent ) Pulsus Paradoxsus Hypotension Muffled heart sounds

    61. ECG Low voltage complexes Electrical alternans Diffuse PR segment depressions and or ST segment elevations

    62. Echocardiography Diastolic collapse of right ventricle and right atrium Diastolic collapse of left ventricle more specific

    63. Echocardiography

    64. Common causes of Chest Pain in ER Not Of Immediate Threat To Life

    65. Chest Pain cardiac CAD Chronic Stable Angina Variant angina Cocaine precipating ACS Valvular heart disease : AS / MS / PS Pericarditis Myocarditis Stress induced Cardiomyopathy Cardiac Syndrome X Pheochromocytoma

    66. Variant angina Vasospastic Angina / Prinzmetal Angina Spontaneous episodes of angina in association with ST segment elevation in ECG Patients : Young females with epicardial disease Chest pain often occurs at rest than in exertion Predominantly in morning Chest pain associated with ST elevation in ECG

    67. Variant Angina ECG : ST segment Elevation Stress testing : often normal except when epicardial disease + Coronary Angiogram : often proximal plaque

    68. Cardiac Syndrome X Angina pectoris with normal coronary arteries Chest pain episodes often with exertion Chest pain is associated with ST segment depression in ECG

    69. Cardiac Syndrome X ECG : Normal / ST Segment Depression Stress Testing : ST Segment depression Coronary Angiography : normal epicardial vessels; no vasospasm

    70. Pericarditis Retrosternal and left precordial pain Radiate to left shoulder, neck Aggravated by inspiration , movement, swallowing More in supine position Relieved in sitting and leaning forward position h/o fever + On ex : Pericardial frictional rub

    72. Case 7 A 55 year old female No co morbidities Lost her husband 3 days ago RTA Devoleped sudden onset left sided chest pain On Ex : Pul : 80 / min BP : 100 / 70 mm Hg RR : 20 / min Chest : clear CVS : S1 + S2+ ESM +

    73. ECG

    74. Investigations Cardiac Enzymes : Trop I : 0.4 CK-MB : 35 2D ECHO : Apical Ballooning of left ventricle in end systole Severe Akinesia of distal portion of LV Reduced EF CAG : Normal Coronaries

    75. Tako Tsubo Cardiomyopathy Apical Ballooning Syndrome Elderly females After severe emotional upset Reversible within 3 7 days Normal Coronaries Mech : unknown catecholamines acting on epicardial coronaries

    76. 2D Echocardiogram

    77. Left Ventriculogram

    78. Chest pain Gastrointestinal Any patient at risk for CAD who presents with anginal quality chest pain - r/o myocardial ischemia before being given gastrointestinal diagnosis

    79. GERD Chest pain can mimic angina pectoris Squeezing / Burning pain - Substernal - Radiating - to back Lasting minutes to hours Resolving spontaneously or with antacids Reflux symptoms : dyspepsia / regurgitation / acid taste ECG / Cardiac enzymes / ECHO R/O ACS Diagnosis : Oesophageal manometry / OGDscopy

    80. Mallory Weiss Syndrome h/o non bloody vomiting and retching followed by hemetemesis chest discomfort epigastric / in back Incidence increases with age Associated with alcoholics and hiatus hernia Mallory-Weiss syndrome is characterized by longitudinal mucosal lacerations proximal stomach and distal oesophagus Diagnosis : OGDscopy

    81. Mallory Weiss Tear

    82. Esophageal chest pain Pain provoked by swallowing Pain provoked by postural changes Pain palliated by antacids Inconsistent relationship with exercise Substernal chest pain which doesnt radiate Frequent episodes Nocturnal pain Pain associated with heartburn, acid taste in mouth

    83. Others. Achalasia cardia Oesophageal spasm Nut cracker esophagus Medication induced esophagitis Radiating visceral pain Peptic ulcer disease Cholecystitis Biliary Colic Pancreatitis Appendicitis

    84. Pulmonary Causes Pneumonia pleuritic pain Lung Cancer dull aching pain Sarcoidosis Pleurisy Empyema Empyema necessitans

    85. Musculoskeletal Chest pain Insidious onset Recent repetitive unaccustomed activity Pain : localized or diffuse Positional component Persistant prolonged ( hours days )

    86. COSTOCHONDRITIS : Multiple areas of tenderness in upper costal cartilages at costochondral junctions NO SWELLING TIETZES SYNDROME : Painful nonsuppurative localized swelling of costosternal, sternoclavicular, costochondral joints

    87. Associated conditions Chronic low back ache, young individual : Ankylosing Spondylitis Ocular Inflammation : Ankylosing Spondylitis Behcets Syndrome Diffuse musculoskeletal pain / sleep disturbance : Fibromyalgia Peripheral joint pain and swelling : RA Skin lesion : Psoriatic Arthritis

    88. Neuropathic Pain Herpes zoster Radiculopathy

    89. Psychological Causes Panic attack Panic disorder DSM IV PC

    90. Treat Chest Pain with Respect THANK U