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Hypertensive lady with chest pain

HKCEM College Tutorial. Hypertensive lady with chest pain. author Dr. WONG Hon Kwong , rocky Oct., 2013. The patient. F/61 Triage notes: hypertension, thyroid disease Chest pain since 1½ hours ago, with some SOB and dizziness BP 235/138 mmHg P 84/min SpO 2 99% (RA) T 36 o C.

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Hypertensive lady with chest pain

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  1. HKCEM College Tutorial Hypertensive lady with chest pain author Dr. WONG Hon Kwong, rocky Oct., 2013

  2. The patient • F/61 • Triage notes: • hypertension, thyroid disease • Chest pain since 1½ hours ago, with some SOB and dizziness • BP 235/138 mmHg • P 84/min SpO2 99% (RA) • T 36oC

  3. PQRST of Chest pain • P Provoking /Palliating factors • Q Quality • R Radiation • S Severity • T Thing

  4. History • Medical Notes: • Hx of HT, hyperlipidemia, post RAI hypothyroidism • Chest pain since 1½ hours ago, radiating to back • Some SOB and dizziness • No sweating • Chest pain resolved, but now mainly back pain

  5. Physical Examination • BP 235/138 mmHg • GCS 15 • Limbs power full and symmetrical • Chest clear, AE equal • HS dual, no murmur • Abd soft non-tender, no mass

  6. Differential diagnosis • Thoracic Aortic Dissection (TAD) • AMI/ACS • Acute Pulmonary Embolism (PE) • Pneumothorax • PPU • ………..

  7. What do you want to do next? • ECG

  8. ECG • Sinus rhythm • Q waves III • Nonspecific ST changes lateral leads

  9. What further investigation? • CXR • What to look for in the CXR? • Widened mediastinum • Pneumothorax • Abnormal aortic contour • Depressed L main bronchus • Westermark sign • Heart size • Free gas under diaphragm

  10. CXR findings • Widened mediastinum • Abnormal aortic contour • Deviation of trachea to right

  11. What is your provisional diagnosis? • Thoracic aortic dissection • What will you do next? • Control BP • Pain control • Arrange further Ix to confirm Dx + consult CCU/ICU and cardiothoracic surgeon

  12. CT Thorax

  13. CT findings • Aortic dissection from L subclavian artery to common iliac arteries

  14. Patient admitted to CCU • Consulted cardiothoracic surgeon -> for medical treatment with tight BP control • Tight BP control with IV labetalol and nitroprusside • Changed to oral adalat retard and labetalol with SBP around 120 mmHg • Discharged D10

  15. Acute Aortic Syndrome • Aortic dissection • Intramural haematoma (IMH) • Penetrating atherosclerotic ulcer

  16. Risk factors: • Hypertension (in 75% of TAD cases) • Blunt trauma • Smoking • Cocaine abuse • Pregnancy • Connective tissue disorder • Marfan Syndrome • Erlers-Danlos Syndrome

  17. Mortality of 1% per hour in 1st 24 hours • Prompt diagnosis and treatment is important

  18. Findings on CXR suggestive of aortic dissection: • widened mediastinum >8cm • abnormal aortic contour • calcium sign • L pleural effusion • depression of L main bronchus

  19. Investigation of choice: • Contrast CT thorax • Transesophageal Echo (TEE) • MRI

  20. Contrast-enhanced computed tomography in acute type A aortic dissection shows a complex intimal flap in the ascending aorta (upper arrow). The intimal flap is also visualized in the descending aorta (lower arrow).

  21. Contrast-enhanced computed tomography shows a type A intramural hematoma of the aorta. Note the circumferential hematoma involving the ascending aorta (black arrows) and the crescentic hematoma involving the descending aorta (white arrows).

  22. Contrast-enhanced computed tomography shows an acute penetrating atherosclerotic aortic ulcer with a focal pseudoaneurysm (arrow) involving the proximal descending aorta.

  23. Treatment • Stanford Type A: Surgical • Stanford Type B: • Uncomplicated: • Medical (tight BP control) • Complicated: • Surgical/ Endovascular(stenting/fenestration)

  24. Antihypertensive agents • Beta-blocker : • Labetalol (20-25mg IV Q10 minutes) or • Esmolol(500ug/kg IV bolus Q5 minutes) • Nitroprusside infusion (0.5-3ug/kg/min) • Analgesics • Opioids: • Fentanyl • Morphine

  25. Take home message • Diagnosis requires high index of suspicion • Sudden onset chest pain with back pain, think of aortic dissection (acute aortic syndrome) • Hypertension is the most important risk factor (in 75% of patients) • Contrast CT thorax is the investigation of choice in A&E setting • Hypertension is controlled with IV ß blockers • Surgical treatment is required for proximal dissections (Type A), while medical treatment is recommended for more distal dissections (Type B)

  26. The end

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