pa 650 chest pain june 2012

7/31/2019 PA 650 Chest Pain June 2012

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CHEST PAINER June 16, 2009

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Stratification

RISK

Risk Factors

Who gets what?

List the risk factors

Clinical Suspicion

Testing

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Chief Complaint

What will bepresentingcomplaints?

MALE

FEMALE

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HPI

What are the KILLERS1. Myocardial infarction2. Dissecting aortic aneurysm

3. Pericarditis with tamponade4. PE5. Pneumonia6. Tension pneumothorax7. Rupture esophagus (Boorhaves syndrome)8. Cancer

What are the Most Commons

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Causes

Acute Coronary Syndrome

Aneurysm, Abdominal

Aneurysm, Thoracic

Angina Pectoris

Aortic Regurgitation

Aortic Stenosis

Atrial Fibrillation

Atrial Flutter

Cardiomyopathy, Dilated

Cardiomyopathy, Restrictive

Congestive Heart Failure andPulmonary Edema

Dissection, Aortic

Dissection, Carotid Artery

Dissection, Vertebral Artery

Heart Block, First Degree

Heart Block, Second Degree

Heart Block, Third Degree

Mitral Regurgitation

Mitral Stenosis

Mitral Valve Prolapse

Multifocal Atrial Tachycardia

Myocardial Infarction

Myocarditis

Myopathies

Congestive Heart Failure

Pericarditis and CardiacTamponade

Peripheral Vascular Disease

Premature VentricularContraction

Pulmonic Valvular Stenosis

Shock, Cardiogenic Hypovolemica

Sinus Bradycardia

Superior Vena Cava Syndrome

Syncope

Tetralogy of Fallot

Thoracic Outlet Syndrome

Torsade de Pointes

Transplants, Heart

Ventricular Tachycardia

Wolff-Parkinson-WhiteSyndrome

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Pulmonary

Pulmonary

Asthma

Bronchitis

Chronic Obstructive Pulmonary Disease and Emphysema

Hyperventilation Syndrome Pleural Effusion

Pneumonia, Aspiration

Pneumonia, Bacterial

Pneumonia, Empyema and Abscess

Pneumonia, Immunocompromised

Pneumonia, Mycoplasma

Pneumonia, Viral

Pneumothorax, Iatrogenic, Spontaneous and Pneumomediastinum

Pulmonary Embolism

Pleuritic CP

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Musculoskeletal

Chest Wall Pain

11-50 %

Trauma

Costochondritis

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Other

Psychological

GI Related GERD

Undifferentiated

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ROS

Killers

Cardio

Pulmonary

Associations to DD

Claudication (PAD) increased risk of CAD

Most Common

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Past Medical History

Surgical History

Specifically ask about other disease processes

that increase the risk of whatever you areconcerned about DM

HTN

When was the last time you saw a doctor? Have you ever seen a doctor for blood pressure,

cholesterol, or your heart ?

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Medications & Allergies

Meds that alert you to increased risk

New Meds Antacids, ASA, when & why did you start taking

that medication

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Family History

Tell me about your (mother, father, brothers,sisters) health

Specifically CAD, PAD, Age when problemsstarted or death

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Social History

Occupation Stress

Tobacco Pack years

Alcohol

Do you use any street drugs

If you want to know about Marijuana ? ASK ABOUT COCAINE (re: B-Blocker)

UDS? Unopposed alpha receptors Auto maticallydo a drug screen

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Physical Exam

Vitals and EKG

Constitutional

Skin (xanthoma, splinter hemorrhages) Head

Eyes (copper wire)

ENT (ear creases)

Neck

Heart

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Physical Exam

Lungs

Abdomen

GU (not examined) Musculoskeletal / Extremities

Neuro

Heme-Lymph

Psychiatric (anxious)

Endocrine (thyroid, DM)

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Differential

List 10

Think about the HALMARKS of those ten

Have you asked questions or performed aphysical exam that includes or excludes these

If not what test do you need to Confirm your suspected diagnosis

Exclude the KILLERS

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ER Lab orders

CBC

BMP

LFT if indicated

Lipase

CIP Cardiac Enzymes

PTT/PTT/ INR You need all three (unlike monitoring warfarin)

BNP

D-Dimer (=/-)

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ER Orders

Radiology Chest x-ray

What are you looking for? If you think chest pain is muscle pain are not getting a CT

CT Scan-not used in everyone- if think they arehaving N, CT PE Study (CT Pulmonary Angiogram) CT Angiogram of the Aorta CT Angiogram of the Heart-specialized scanner

CT TRIPLE RULE OUT-aorta angiogram abd aortaangiogram out PE

Other test as indicated to rule out differentials

Pts are taken to cath lab every day on sxs alone.They are not done emergency, price $1500

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ER Medication Orders

ASA ON ARRIVAL

If EKG changes that indicate MI or Angina, or High ClinicalSuspicion go right to the ACS PROTOCOL and Notify

Cardiology Remember CXR BEFORE Starting Heaprin https://www.musc.edu/cce/ORDFRMS/pdf/cpedadmit.pdf https://www.musc.edu/cce/ORDFRMS/pdf/ah_card_cardiologyhe

parinprotocol.pdf

Nitroglycerine (based on suspicion) 0.4 mg SL-see if it helps pain can also help with esophageal pain

as well 1-2 inches of paste to chest IV Infusion (drip) 5 or 10 micrograms / min

You will titrate this to pain AND BP or hypotensive

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https://www.musc.edu/cce/ORDFRMS/pdf/cpedadmit.pdfhttps://www.musc.edu/cce/ORDFRMS/pdf/ah_card_cardiologyheparinprotocol.pdfhttps://www.musc.edu/cce/ORDFRMS/pdf/ah_card_cardiologyheparinprotocol.pdfhttps://www.musc.edu/cce/ORDFRMS/pdf/ah_card_cardiologyheparinprotocol.pdfhttps://www.musc.edu/cce/ORDFRMS/pdf/ah_card_cardiologyheparinprotocol.pdfhttps://www.musc.edu/cce/ORDFRMS/pdf/cpedadmit.pdf


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ER Chest Pain Workup

Oxygen

Nitroglycerine (based on suspicion)

0.4 mg GI Cocktail

EKG

CXR CMB, BMP, Trop, INR, UDS, D-Dimer

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Delta (change)

An approach using the change in biomarkers over two hours wasinvestigated in a comprehensive strategy of chest pain testing.There was a 93 percent sensitivity for acute myocardial infarctionwithin 24 hours using a two hour strategy incorporating baselineECG, cardiac markers, two hour delta CK-MB, two hour delta

troponin and serial ECGs

In a similar investigation, delta CK-MB was more accurate thanmyoglobin for diagnosing early myocardial infarction.

However, the sensitivity of the delta CK-MB varied from 73 to 93percent depending on the cutoff used, emphasizing theimportance of using an appropriate threshold for a positivechange

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Now What?

When you have positive findings its easy

What if everything is normal-what do you do, a lot is clinicalsuspicion, we can call cardiologist and see if they will hold

overnight and stress test the pt. PA may stress them and theysend them to

Admit-If having a stemi, unstable angina

Discharge Medicine follow up Cardiology follow up

____ hrs. observation

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Should I stay or should I go?

CP with identified cause

Depend on the cause

CP with ekg changes CP 1 risk factor

CP 2 risk factors

CP 3 risk factors CP 4 risk factors

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Escalating the outpatient

workup

H &P / Risk factors

REVIEW OF RECORDS EKG & CXR

Compare to previous

Early pathology may not show up

Resting EKG Functional testing

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Functional Testing

Stress

Walking or nuclear

Stress echo

Wall motion abnormality

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Cardiac Catheterization

Virtual

TRO

heart center

Real

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Outpatient

Stress Testing

Holter Monitor (24-48 hrs)

Event Monitor (30 days) Tilt Table-look up

EP Studies-look up

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Observation

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pa 650 chest pain june 2012

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