Medical collage of wassit

Seminar about:

approach to chest pain

By:

Mustafa BasharSaif SahebAhmed AyadAli AkramAhmed Majed

A 63-year-old man presented to the emergency department complaining of severe shortness of breath that began abruptly when he bent over to pick up some papers. He reported that as he reached down he suddenly was not able to catch his breath, felt lightheaded, and collapsed to the floor without any loss of consciousness.

He complain of severe central chest pain and diaphoresis .

One week prior to this event, the patient reported that he began to notice pain and swelling in his right calf .

He had no significant past medical history .

Social history was significant for a 50 pack per year smoking history and alcohol consumption of approximately one bottle of wine daily for many years .

His mother had a history of phlebitis. The patient denied taking any medications and had no known drug allergies

His vital signs upon arrival of emergency medical services were a palpable systolic blood pressure of 50 mmHg, a heart rate of 134 beats per minute, a respiratory rate of 40 per minute with an oxygen saturation of 80% breathing air. On arrival to the emergency department, his oxygen saturation was to 95% on a 100% non-rebreather facemask

He was pale, diaphoretic, and unable to speak in full sentences and low urinary output. His jugular veins were distended to the angle of the jaw while the patient was sitting upright at 90 degrees and was later measured at approximately 20 cm.

Cardiac exam

demonstrated tachycardia, a fixed wide of the second heart sound, the presence of a third heart sound at the left lower sternal border, and a right ventricular heave

Pulmonary findings consisted of bilateral crackles at the bases.

His extremities were cool and cyanotic with weak peripheral pulses.

Show ventilation-perfution mismatch and reduced cardiac output .also reduced Pao2

and low Paco2

D-dimer is elevated

Circulating markers such as troponin I & pro-brain natriuretic peptide

diagnosis confirmed by

Ventilation-perfusion scanning has been the most popular method of attempting to confirm the presence of PE The sensitivity and specificity of V/Q scanning is greatly increased when interpretation is informed by clinical probability. A normal V/Q scan virtually excludes PE and a low probability scan in the presence of a low clinical probability makes PE unlikely. Similarly, the presence of a high probability scan [V\Q mismatch ]in a patient with a high clinical probability almost certainly establishes the diagnosis of PE. V/Q scans are most useful in patients with normal pulmonary architecture..

Colour doppler ultrasound of the leg to confirm DVT in patiant with clinical suspention of DVT

Echocardiography show acute dilatation of the ventricle

Pulmonary CT angiography is the gold standard for diagnosis

General measures

Oxygen

Opiates

Diuretics and vasodilators should be

Avoided

Resuscitation by external cardiac massage may be successful in the moribund patient by dislodging and breaking up a large central embolus.

Low molecular weight heparin administered subcutaneously is more effective than intravenous unfractionated heparin and it is easier to administer). The dose is standardized for the weight of the patient and does not require monitoring by tests of coagulation. Heparin is effective in reducing mortality in PE by reducing the propagation of clot and the risk of further emboli. It should be administered for at least 5 days and anticoagulation continued using oral warfarin. Heparin should not be discontinued until the international normalized ratio (INR) is greater than 2. An alternative for the initial LMWH therapy is fondaparinux, which can be given as a once-a-day SC injection of 2.5 mg, without laboratory monitoring

Appears to improve outcome when acute massive PE is accompanied by shock but it is not clear whether there is any advantage of thrombolysis over heparin in patients with a normal blood pressure. Patients with PE appear to have a high risk of intracranial haemorrhage .

Caval filters

Patients who experience recurrent PE despite adequate anticoagulation, or those patients in whom anticoagulation is contraindicated, may benefit from insertion of a filter in the inferior vena cava below the origin of the renal vessels. The introduction of retrievable cavalfilters has been useful in patients with temporary risk factors.

A 45 year old white male presents with chief complaint of episodes of recurrent chest pain. Past medical history is noncontributory. He says the chest pain is like a deep pressure in the left chest. It does not radiate and lasts just a few minutes. It has occurred at rest and with exercise, and occasionally with a big meal. It has been reoccurring over the last several months. He occasionally gets diaphoretic with the pain but not always. He also has some dyspnea associated with the chest pain when he has exercised. He is not currently having pain, and his last epoisodewas this morning as he was shoveling snow off his front walk

What`s next?

Cardiac enzym

Negative

Patients should be admitted urgently to hospital

bed rest

antiplatelet therapy (aspirin 300 mg followed by 75-325 mg daily long-term and clopidogrel 300 mg followed by 75 mg daily for 12 months

anticoagulant therapy (e.g. unfractionated or fractionated heparin)

β-blocker (e.g. atenolol 50-100 mg daily or metoprolol 50-100 mg 12-hourly)

A dihydropyridine calcium antagonist (e.g. nifedipine or amlodipine) can be added to the β-blocker, but may cause an unwanted tachycardia if used alone; verapamil or diltiazem is therefore the calcium antagonist of choice if a β-blocker is contraindicated.oral isosorbid dinitrate and If pain persists or recurs, infusions of intravenous nitrates (e.g. GTN or isosorbide dinitrate may helpStatin drugs should be used to stabilized the plaque

A 45-year-old male presents to the local Emergency Department with complaints of moderate to severe chest pain, with radiation to the neck-shoulder region. The patient denies any personal history of heart disease, but reports that his father passed away from a heart attack at the age of 69. Temperature = 38.3º c. Pulse = 110. Respiratory rate = 25. Blood pressure = 100/63. During pulmonary auscultation, the patient states that pain gets much worse every time he is asked to take a deep breath. The patient refuses to lie down for the abdominal exam, saying that the pain gets too bad when he is supine. An EKG is ordered, and shows ST elevation in all leads except for V1 and aVR. PR depression is noted. Troponin I is mildly elevated.

HISTORY Chest pain, which may

intense,retrosternal radiate to shoulders and to the back but characteristically sharp, pleuritic, and positional (relieved by leaning forward); typically aggravated by deep breathing, movement, a change of position, exercise and swallowing.

Rapid pulse, pericardial friction rub, which may vary in intensity and is loudest with pt sitting forward.

Aspirin 650–975 mg qid or NSAIDs (e.g., indomethacin 25–75 mg qid); for severe, refractory pain, prednisone 40–80 mg/d is used and tapered over several weeks or months. Intractable, prolonged pain or frequently recurrent episodes may require pericardiectomy. Anticoagulants are relatively contraindicated in acute pericarditis because of risk of pericardial hemorrhage

1. Which of the following conditions constitutes the most likely diagnosis in this patient’s case?

A. myocardial infarctionB. Dressler’s syndromeC. pericarditisD. hypertrophic subaortic stenosisE. cardiac tampanode

2. Which of the following methods represents the most appropriate next diagnostic step in working up this patient’s condition?

A. angiographyB. CT scanC. technetium-99 perfusion scanD. magnetic resonance imagingE. echocardiography

3. Which of the following represents the most appropriate treatment in the management of this patient?

A. non-steroidal inflammatory drugsB. cardiac catheterization with angioplastyC. coronary artery bypass graft procedureD. emergent IV administration of heparinE. pericardiocentesis

43 years old patient presents with sever chest pain that will not stop. the pain are a pressure that feels like an elephant sitting on his chest. It radiates to his left arm and he is very diaphoretic. He denies any dyspnea, but he complain from nausea and vomiting. He started having chest pain at home while digging up a tree.

Troponin appearing in 3-6 hours

CK isoenzymes MB appearing 4-8 hours

LDH within 24 hours and AST

Erythrocyte Sedimentation Rate appearing 3 days after

Leukocytes within several hours and peaking within 2-4 days (if your in a rural area a stat

CBC may give you a hint of possible myocardial infarction)

Inferior infarcts involve the inferior portion of the heart which sits on the diaphragm. Irritation or somato-somatic reflexes could cause nausea and vomiting due to adrenergic innervation through common pathways.

EARLY MANAGEMENT

Any Patients with suspected acute MI require .immediate addmition to hospital

High-flow oxygen

I.v. access

I.v. analgesia (opiates) and antiemetic : Intravenous opiates (initially morphine sulphate 5-10 mg or diamorphine 2.5-5 mg) and antiemetics (initially metoclopramide 10 mg) should be administered through an intravenous cannula and titrated by giving repeated small doses until the patient is comfortable

Aspirin 300 mg : chewing

Heparin either infusion or low molecular weight S.c

Primary PCI or thrombolysis:

Streptokinase, 1.5 million U in 100 ml of saline given as an intravenous infusion over 1 hour-

-alteplase: The standard regimen is given over 90 minutes (bolus dose of 15 mg, followed by 0.75 mg/kg body weight, but not exceeding 50 mg, over 30 minutes and then 0.5 mg/kg body weight, but not exceeding 35 mg, over 60 minutes).

tenecteplase -

Reteplase -

Intravenous heparin should be given for 48-72 hours following thrombolysis with alteplase, TNK or reteplase.

Beta-blockers Intravenous β-blockers (e.g. atenolol 5-10 mg or

metoprolol 5-15 mg given over 5 minutes) relieve pain, reduce arrhythmias and improve short-term mortality in patients who present within 12 hours of the onset of symptoms, but should be avoided if there is heart failure, atrioventricular block or severe bradycardia.

Nitrates and other agents Sublingual glyceryl trinitrate (300-500 μg) is a

valuable first-aid measure in threatened infarction, and intravenous nitrates (nitroglycerin 0.6-1.2 mg/hour or isosorbide dinitrate 1-2 mg/hour) are useful for the treatment of left ventricular failure and the relief of recurrent or persistent ischaemic pain.

A 18-year-old male patient came to the emergency department with complaints of sudden onset of pleuritic chest pain in the left side stabbing in nature radiated to epsilateral soulder and shortness of breath after cough which started 6 hours ago. The shortness of breath was mild in severity, the symptoms worse by exertion and relieved with rest

Respiratory distress

Tachypnea

Asymmetric lung expansion.

Decreased tactile fremitus

Hyperresonance on percussion

Distant or absent breath sounds

what is treatment?

In many cases we need only observation and serial CXR follow up daily , the air will be absorbed.

In the simple(closed) spontanouspneumothorax, if the volume of the air in that side is less than 20% of the size of that hemithorax and the patient has little symptoms such as dyspnea ,then conservative treatment is justified , however if the underlying lung is diseased ( Tb , emphysema) active intervention is indicated even if the size of the pneumothorax is near 20% of the hemithorax.

In the open type if the lung in serial CXR shows no improvement ,then chest tube introduced in the pleural space to facilitates lung expansion and when the lung expands the pleural layers come in contact with each other so the opening may seal ,sometimes we may use suction through the chest tube to create more –ve pressure inside the pleural space to help rapid lung expansion . If this does not lead to re-expansion of the lung it means that broncho-pleural fistula has been developed and surgical repair is indicated

Tension pneumothorax is an emergency state and needs urgent intervension, by chest tube .

49-year-old male, otherwise healthy Presenting complaint is retrosternal burning

pain , have been ongoing for approximately six months At onset, retrosternal burning was occurring one to two times per week, mainly after meals Symptoms do not worsen with activity or inspiration, but often worse when bending over or lying flat ,Over the last month, symptoms have been occurring on a daily basis, with the patient occasionally awakening at night with similar symptoms which disturb sleep

Patient appears generally well nourished

BP 132/70, pulse 84 bpm, afebrile

Current weight 102 kg; height 178 cm

No conjunctival pallor, no scleral icterus

Oral cavity normal, normal dentition

Save for central obesity, remainder of physical exam within normal limits

When we do endoscope for this patient ?

The presence of alarm signs – specifically significant weight loss, dysphagia, hematemesis, or melena – is an indication for endoscopic evaluation to rule out esophageal strictures or malignancy.

What`s the line of treatment?

1-change life style

2-medication

-antacid

-h2-antagonast

-PPI

45 y .old male complaining of chest pain , burning, tickling, tingling, and/or numbness occurs in the left parasternal area … Flu-like symptoms (without a fever), such as chills, stomachache.

Also there is Swelling and tenderness of the lymph nodes …

.then after 5 days the patient develop small area of rash Then blisters develop

Pain, described as "piercing needles in the skin ……

Q1 // what is the most likely diagnosis ??

Shingles (( herpes zoster ))

Q2/ what are the investigations of choice for such case ??

:InvestigationThe diagnosis is usually clinical, based on typical lesions in a single dermatome. Various techniques to detect the virus or antibody detection may be possible after consultation with a microbiologist. Scraping for smears and cultures are usually negative, as the viruses are difficult to recover from the scrapes. A direct immunofluorescenceassay can be used; it is more sensitive than viral culture and can differentiate herpes simplex viral infections from varicella-zoster virus (VZV) infections.

Where the presentation is atypical (eg, a young patient, severe disease or a rash extending beyond one dermatome), the patient needs to be investigated for immunodeficiency.

Q3 // what are the treatment of choice ???

TREATMENT :::::1 - Topical therapy

Topical antiviral treatment is not recommended. Topical antibiotic treatment may be indicated for secondary

bacterial infection .

::2- Oral antiviral therapy

Oral aciclovir has been shown to shorten the duration of signs and symptoms

3- Steroids :

The use of oral corticosteroids in the treatment of patients with zoster infection is controversial. As an adjuvant option in the treatment of patients with acute zoster infection, oral corticosteroids have been shown to ameliorate the inflammatory features and so reduce pain, and cosmetically improve the rash.

4- AnalgesiaIt may be necessary to give quite strong analgesia if there is pain. Corticosteroids, tricyclic antidepressants, gabapentin, and opioids reduce acute pain

Case

8

case 8 Awell nourished obese women admitted to hospital to emergency room at mid night … complaining from acute state of shock with Sudden severe chest and upper back pain, often described as a tearing sensation, that radiates to the neck and down the back between the scapula.

Also there is Shortness of breath and Sudden difficulty speaking, loss of vision, weakness, of one side of body, and Sweating

Then the patient loss her consciousness at emergency department ..

physical examination findings include the followings ( signs ) :

Weak pulse in one arm compared to the other .

Hypotension

muffled heart sounds

diastolic murmur

Asymmetrical pulses

What`s the next ?

Q1// WHAT is THE MOST LIKELY diagnosis

???

DISSECTING AORTIC

ANEURISM

Q2// WHAT ARE THE other

APPROPRIATE INVESTIGATIONSFOR SUCH CASE

???

1- Transthoracic/transoesophageal ultrasound will give an indication of site and extent of dissection

2- MRI scanning will confirm diagnosis, and identify involvement of other vessels, and will be increasingly useful as scanning times decrease, and with better access. Of all of the imaging modalities it has the best sensitivity (98%) and specificity (98%) .

3- Colour flow Doppler is useful for assessing aortic regurgitation

4-ecg showing ACUTE MI like features (There will be ECG signs of acute myocardial infarction if this is present and this could lead to thrombolytic therapy.

Double aortic knob sign (present in 40% of patients)

Diffuse enlargement of the aorta with poor definition or irregularity of the aortic contour

Inward displacement of aortic wall calcification by more than 10 mm

Tracheal displacement to the right Pleural effusion (more common on the left side;

suggests leakage) Pericardial effusion Cardiac enlargement Left apical opacity

Q3// WHAT ARE THE DDX ??

Differential diagnosis ::::

Acute coronary syndrome with and without ST elevation.

Aortic regurgitation without dissection.

Aortic aneurysms without dissection.

Musculoskeletal pain.

Pericarditis.

Mediastinal tumours.

Pleuritis.

Pulmonary embolism.

Cholecystitis

Q3// WHAT ARE THE TREATMENT ??

TX :A -General measures -Intravenous access.

Adequate analgesia - eg, morphine.

Transfer to an intensive care unit or high dependency unit.

aggressive blood pressure control

.

There may be evidence of blood loss due to sequestration of blood. Separate lines are required for administration of blood and drugs.

Surgery

Surgical intervention may involve the placing of stents or grafts to the aorta but accurate assessment is essential first, as there may be entry, re-entry and multiple tears

Case :19-years old alcoholic male came to doctor complaining of sever epigastric pain radiated to back and chest ,with nausea and vomiting, increased heart rate with fever and weakness .the patient had history of gallbladder stone, ,

What`s the next ?

show>>Laboratory investigations:

elevatedserum amylase ………………..elevatedbilirubin ……………...

elevatedserum alkaline phosphate..

AST&ALT …………elevated

-Ultrasound can show a swollen pancreas, dilated common bile duct and free

peritoneal fluid .

-It is useful to detect the presence of gallstones

What are the likely dx ?????

Acute pancreatitis

Other mode for dx ?

1.C.T

2.Chest X-ray

treatment::::

Self care at home Stop alcohol

Diet improvement

Medical care Objective- relieve symptoms and stop progression

Admit to hospital

Maintenance of oxygenation

Maintenance of IV line

Medication for pain and nausea

Antibiotics in certain settings

Bowel rest by NPO

Nasogastric intubation

Nutritional supplementation

Surgery Only done to remove the etiological factor e- g

cholecystectomy in case of gall stones

Early ERCP and sphincterectomy with stone extraction

In complicated cases surgical procedures required as per consultation

General information

Present on Admission:

Age greater than 55 years

WBC greater than 16,000/ul

Blood glucose greater than 200 mg/dl

Serum LDH greater than 350 I.U./L

SGOT (AST) greater than 250 I.U./L

Hematocrit fall greater than 10%

BUN increase greater than 8 mg/dl

Serum calcium less than 8 mg/dl

Arterial oxygen saturation less than 60 mm Hg

Base deficit greater than 4 m eq/L

Estimated fluid sequestration greater than 6000 ml (6 liters)

A 20-years old female presented with pain in right upper quadrant and referred pain of right shoulder tip also nausea ,vomiting ,fever on examination revealed right hypochondrial tenderness , rigidity and gallbladder mass,what is your next step?

What are the most likely dx ???

Acute cholecyctitis

What are the investigations

???

FBC - the WbC are raised.

Liver enzymes are mildly abnormal.

Ultrasound findings for cholecystitis:

Include a thickened gallbladder wall (greater than 3 mm) and may also include pericholecystic fluid or air in the gallbladder or the gallbladder wall.

If the gallbladder wall is thickened but there are no gallstones present then the diagnosis could still be acalculus cholecystitis

What are the treatment ???

treatment:

Bed rest ,pain relief(diclofenac or pethidine) ,antibiotic and maintenance of fluid balance.

If your GP suspects you have acute cholecystitis, you will probably be admitted to hospital for treatment.

Antibiotics

You will first be given an injection of antibiotics into a vein. Broad-spectrum antibiotics are used, which can kill a wide range of different bacteria .

Once your symptoms have stabilised, you may be sent home and given an appointment to return for surgical treatment

Alternatively, if your symptoms are particularly severe or you have a high risk of complications, you may be referred for surgery a few days after antibiotic treatment.

A cholecystectomy is the most widely used type of surgery for cases of acute cholecystitis.

thanx