chest pain.ppt 0

8/13/2019 Chest Pain.ppt 0

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Chest Pain

LSU Medical Student Clerkship,

New Orleans, LA


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Chest Pain

Goals

Review the pathophysiology, diagnosis and

treatment of life threatening causes of chest pain.


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Chest Pain

Epidemiolog

5% of all ED visits

Approximately 5 million visits per year


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Chest Pain

!isceral Pain

Visceral fiers enter the spinal cord at several levels leadingto poorly locali!ed, poorly characteri!ed pain. "discomfort,

heaviness, dull, aching#

$eart, lood vessels, esophagus and visceral pleura are

innervated y visceral fiers

ecause of dorsal fiers can overlap three levels aove or

elow, disease of thoracic origin can produce pain

anywhere from the &aw to the epigastrum


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Chest Pain

Parietal Pain

'arietal pain, in contrast to visceral pain, isdescried as sharp and can e locali!ed to the

dermatome superficial to the site of the painful

stimulus.

(he dermis and parietal pleura are innervated

y parietal fiers.


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Chest Pain

"nitial ApproachA)*s first, always "loo+ for conditions reuiring

immediate intervention#Aspirin for potential A)-

E/

)ardiac and vital sign monitoring 'ain relief

ecause of the wide differential, $0' will guide the

diagnostic wor+up


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Chest Pain

#istor

12 onset

'2provocation 3palliation

42 uality3uantity

R2 region3radiation

-2 severity3scale

(2 timing3time of onset


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Chest Pain#istor

)hange in pain pattern

Associated symptoms D1E, -1,

diaphoresis, vomiting, heart urn, foodintolerance

'$x

-ocial history

6$x


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Chest Pain

Phsical E$am

/eneral Appearance and Vitals "sic+ vs not sic+#

)hest exam27nspection "scars, heaves, tachypnea, wor+ of

reathing#

2Auscultation "murmurs, rus, gallops, reath sounds#

2'ercussion "dullness#2'alpation "tenderness, '87#


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Chest PainPhsical E$am

9ec+ :VD, crepitence, ruits

Adomen

Extremities swelling, pulses, tenderness,$oman*s


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Chest Pain

)ardiovascular Acute myocardial infarction, Acute coronary ischemia, Aortic dissection, )ardiactamponade, ;nstale angina, )oronary spasm, 'rin!metal


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Chest Pain

Li&e 'hreatening Causes o& Chest Pain

Acute )oronary -yndromes 'ulmonary Emolus

(ension 'neumothorax

Aortic Dissection Esophageal Rupture

'ericarditis with (amponade


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Chest Pain

Acute Coronar Sndromes ( Epidemiolog

7n a typical ED population of adults over the age

of >? presenting with visceral2type chest pain,aout @5 percent will have A87 and 5 to >?

percent will have ;A


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Chest Pain

Acute Coronar Sndromes ( #istor

B(ypicalC )hest 'ain -tory "'ressure2li+e,

suee!ing, crushing pain, worse with exertion,-1, diaphoresis, radiates to arm or &aw# (he

ma&ority of patients with A)- D1 91( present

with these symptoms

)ardiac Ris+ 6actors "Age, D8, $(9, 6$,

smo+ing, hypercholesterolemia, cocaine ause#


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Chest Pain

Acute Coronar Sndromes ) E*G +indings

-(E87 2 -( segment elevation "@ mm# in

contiguous leadsF new G ( wave inversion or -( segment depression in

contiguous leads suggests suendocardial

ischemia

5% of patients with A87 have completely normal

E/s


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Chest Pain


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Chest Pain


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Chest Pain

Acute Coronar Sndromes ) Cardiac Markers

8ar+er 7nitialRise

'ea+ Return tonormal

enefits

(roponin 2H hr @? 2H hr 5 2@? days -ensitive and specific

)28 >2H hr @?2H hr I H days ;naffected y renal failure

GD$ @? hr H 2J hr @H days

8yogloin @2 hr H 2K hr H hours Very sensitive, powerfulnegative predictive value


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Chest Pain

Acute Coronar Sndromes ) Cardiac Markers


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Chest PainEchocardiogram

=all anormalities occur within minutes

=ill detect anormalities in K?% of A87

9ormal resting echo in setting of chest paingives low proaility

Early screen for A87 complications

aneurysms, valve anormalities, other

structural destruction


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Chest PainEcho


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Chest Pain

Acute Coronar Sndromes ( 'reatment

Aspirin

9itroglycerin1xygenAnalgesia


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Chest Pain


Aspirin

9itroglycerin1xygenAnalgesia


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Chest Pain'reatment

eta2loc+ersAnticoagulation

Anti2'latelet Agents(hromolysis'ercutaneous )oronary 7nterventions

"')7#


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Chest PainStress echocardiograms

-ensitivity L?2M?%

-pecificity J5% N

-hould e employed with moderate to highris+ stratification

Gimitations of reader, image uality, and

previous functional impairment

9egative test has time limited value


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Chest Pain


-(E87 "A-A, 2loc+er, 9(/, anti2platelet,

anticoagulation, thromolysis, ')7#

9-(E87 "A-A, 2loc+er, 9(/, anti2platelet,

anticoagulation, ')7#

;nstale Angina "A-A, 2loc+er, 9(/,

anticoagulation, ris+ stratification#


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Chest Pain

Acute Coronar Sndromes ( %isposition

8ortality is twice as high for missed 87

8issed 87 is the most successfully litigatedclaim against E'


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Chest Pain

Acute Coronar Sndromes ( %ispositionA single set of cardiac en!ymes is rarely of use

Ris+ -tratification goal is to predict theli+elihood of an adverse cardiovascular event

)omination of $0', E/, iomar+ers9o single gloally accepted algorithm8athematical models such as (787, /RA)E,

';R-;7(, and $EAR( can e helpful ut areno sustitute for clinical &udgment


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Chest Pain

Pulmonar Emolism ( Pathophsiolog

(hromosis of a pulmonary artery

M?% arise from DV()lot from a DV( travels through the venous

system and lodges in the pulmonary vasculature

creating a ventilation3perfusion mismatch


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Chest Pain

Pulmonar Emolism ) #istor

Dyspnea is the most common symptom, present

in M?% of patients diagnosed with 'E-harp pleuritic chest pain, syncope,

'rolonged immoili!ation, neoplasm, +nown

hypercoagulale disorder


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Chest Pain

Pulmonar Emolism ) Phsical E$am

(achycardia, tachypnea, diaphoresis,

hypotension, hypoxia, low grade fever, anxiety,cardiovascular collapse, right ventricular heave


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Chest Pain

Pulmonar Emolism ) %iagnostic 'esting

-inus (achycardia is the most freuent E/

finding)lassic -@,4>,(> finding is seen in less than

?%

A/ plays no role in ruling out 'ED2Dimer in a low ris+ patient can e used to rule

out 'E


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Chest Pain

Pulmonar Emolism ) -ells Criteria

Clinical Signs and Smptoms o& %!'. /es 01 PE is 23 %iagnosis, or E4uall Likel. /es 01 #eart 5ate 6 377. /es 0389 "mmoili:ation at least 1 das, or Surger in the Pre;ious

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