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Chest Pain William Beaumont Hospital Department of Emergency Medicine

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1 Chest Pain William Beaumont Hospital Department of Emergency Medicine
Shanna Jones, MD

2 The Things That Kill… Acute MI Pulmonary Embolus (PE)
Pneumothorax (PTX) Aortic Dissection Esophageal Rupture (Boerhaave’s)

3 Let’s dive right in…

4 Chest Pain: What is it? 65 y/o male complains of substernal chest pressure and tightening that radiates to his left arm, shortness of breath, diaphoresis, and nausea that started while working in the yard. PMHx: HTN, high cholesterol Soc: + tobacco FHx: father died at 62 of MI

5 Chest Pain: What is it? 86 y/o female presents with generalized weakness, mental status changes, vomiting, epigastric pain, and syncope after her last episode of vomiting. There is no other history as the NH did not feel it was necessary to send her records.

6 Chest Pain: What is it? 36 y/o obese, diabetic male presents with weakness, fatigue. shortness of breath whenever he gets off the couch, and “just not feeling right, doc.” PMHx: diabetes since his teens, HTN, high cholesterol FHx: Mom – HTN; Dad – “had a bad heart”

7 Acute Coronary Syndrome (ACS)
Includes USA, NSTEMI, STEMI Leading cause of death among adults in the US (about 1 million, 2006) 6 million people present to the ER per year with chest pain 2 million of these receive the diagnosis of ACS Cost of doing business: $ billion

8 Risk Factors for CAD – Typical
Male Older Age Tobacco HTN DM High Cholesterol FHx Cocaine Artificial/early menopause

9 Risk Factors for CAD – Atypical
DM Elderly Female Nonwhite Dementia No history of MI No history of high cholesterol CHF CVA

10 Unstable Angina (USA) Defined
New onset angina occurring with minimal exertion or at rest, worsening of previous angina, increased frequency or duration of attack, and resistance to previous treatment ECG: normal/unchanged, nonspecific ST segment changes, or T wave inversions

11 Acute Myocardial Infarction (AMI) Definition
Rise and fall of cardiac biomarkers with the following Ischemic symptoms (critical vessel stenosis with increased myocardial work load or plaque rupture) Development of Q waves on ECG ST segment elevation or depression (STEMI & NSTEMI) Coronary artery intervention (lytics or cath lab)

12 NSTEMI Definition Positive cardiac enzymes in the appropriate clinical scenario without ST elevation on the ECG ECG – normal, T wave inversions, ST segment depressions

13 ECG Findings of ACS Hyperacute T waves ST segment elevation of 1 mm
ST segment depression – NSTEMI vs reciprocal changes T wave inversions – initial presentation or evolving infarct Q waves – may emerge in the initial hour, but usually develop at 8-12 hours Normal ECG

14 Injury Patterns on the ECG
Anterior wall MI: ST segment elevation V1-V4 Vessel: LAD

15 Injury Patterns on the ECG
Anterior wall MI: ST segment elevation V1-V4

16 Injury Patterns on the ECG
Lateral Wall MI: I, aVL, V5, V6 Vessel: variable perfusion of LAD, RCA, LCx

17 Injury Patterns on the ECG
Anterolateral with reciprocal changes Vessels: LAD and 1st diagonal branch

18 Injury Patterns on the ECG
Inferior wall MI: II, III, aVF Vessel: 90% RCA, 10% LCx

19 Injury Patterns on the ECG
Posterior Wall MI: V1-V3 depression, tall upright T, tall wide R wave, R/S ratio greater than 1 Vessel: RCA, PDA, LCx

20 Injury Patterns on the ECG
Inferior Wall MI with Posterior Wall MI: V1-V3 depression, tall upright T, tall wide R wave, R/S ratio greater than 1 Vessel: RCA, PDA, LCx

21 Moving on… What do you want to order in addition to an ECG for a patient presenting with chest pain, suspected ACS?

22 Initial Evaluation IV, O2, monitor Focused H&P CBC Chem 7
CK-MB, troponin, myoglobin CXR PT/PTT Possible D-dimer ? Repeat ECG

23 Treatment in the ED: STEMI
Activate the acute MI page and cath lab ASA 325mg PO – proven to save lives NTG SL and gtt – reduces preload>afterload, dilates coronary arteries Heparin 60 U/kg bolus then 16 U/kg/hour ? Beta Blocker – decrease catecholamine driven tachycardia and contractility, therefore decreasing myocardial oxygen demand

24 Treatment in the ED: STEMI
Morphine – for persistent pain or anxiety to reduce O2 need, weak sympathetic blocker, preload reducer through venous dilation Glycoprotein IIb/IIIA inhibitors – started in the EC or cath lab for those patients undergoing mechanical coronary intervention Plavix – in consultation with the cardiologist as it prohibits CABG for 5 days

25 Treatment in the ED: STEMI Reperfusion Therapy
PCI – 90 minute rule Most people are eligible Decreased risk of bleeding and stroke Higher initial reperfusion rates Defines coronary vasculature and allows for treatment vs. surgical referral t-PA – when PCI cannot be achieved in 90 minutes or is not available 0-12 hours after symptom onset

26 NTG When to think twice?

27 NTG: Be cautious… Bradycardia Hypotension
Inferior or posterior wall MI with RV INFARCT Decreased preload will cause sudden hypotension and increase infarct size These patients need fluids to increase preload and help fill the malfunctioning/weakened ventricle

28 Treatment in the ED: USA/NSTEMI
Basically the same, but without the cath lab or fibrinolytics IV, O2, monitor ASA, heparin, NTG, ? beta blocker, morphine Plavix and GIIb/IIIa inhibitors potentially after discussion with cardiology Admit to a monitored unit

29 Chest Pain: low risk, but risky enough
Patients who are low risk with risk factors (silly isn’t it?), chest pain free, and have a normal ECG and enzymes Observation unit for serial cardiac enzymes and ECG Stress test vs. CTA Cardiology consult variable

30 Chest Pain: What is it? 38 y/o female presents with sudden onset of chest pain and shortness of breath after retrieving her bags at the baggage claim from a flight home from Hawaii. She states that it is worse when she takes a deep breath. She also complains of this aching pain in her right leg when walking.

31 Chest Pain: What is it? 80 y/o bedridden patient sent from the NH with mental status changes and hemoptysis. She is pleasant during the conversation, but has no idea why she is here. She is actively coughing and appears to have increased work of breathing. PMHx: positive for almost everything (she is 80) Vitals: HR 110, BP 90/60, RR 28, sPO2 88% RA Lungs: bibasilar rales with right mid lung rhonchi

32 Pulmonary Embolism – 2006 Stats
Approximately 1 in every EC patients has a PE EM MDs correctly diagnose about 50% 10% of EC patients with PE die within 30 days even when PE is promptly diagnosed and treated

33 PE – Risk Factors Carcinoma Immobility
Trauma or surgery in the last 4 weeks Smoking Estrogen/OCP Pregnancy/PP Thrombophilia Connective Tissue Dz Prior PE or DVT

34 PE – Signs and Symptoms Chest Pain Dyspnea Hemoptysis Splinting
Syncope HR > 100 Pulse ox < 95% Unilateral arm or leg swelling

35 PE – Diagnosis Basic Labs – CBC and Chem 7
? Labs – CK-MB, troponin, PT/PTT D-dimer – low risk patients only with low pretest probability CXR Exclude other diagnosis – CHF, PNA, PTX Unilateral basilar atelectasis increases the probability of PE Hamptom’s hump – wedge shaped infarction Westermark’s sign – unilateral lung oligemia

36 PE – Hampton’s Hump

37 PE – Westermark’s Sign

38 PE – Diagnosis ECG Again to exclude other diagnosis Most common finding is sinus tachycardia T wave inversions V1-V4 McGinn-White Pattern – S1Q3T3 New incomplete or complete RBBB Chest CT – moderate to high risk patients or pre-test probability, positive D-dimer

39 PE – ECG

40 PE – ECG

41 PE – Treatment LMWH 1 mg/kg SQ q12 hours
Heparin unfractionated 80 U/kg bolus then 18 U/kg/hr LMWH 1 mg/kg SQ q12 hours Coumadin – usually started on the floor

42 PE – Treatment IVC filter – for pts who failed anticoagulation or have contraindications Thrombolytics – consider in high risk pts such as systolic hypotension, persistent hypoxemia, elevated troponin or BNP (early shock or shock) Surgery – large clot burden, refractory hypotension, floating emboli in the R heart

43 Chest Pain: What is it? 18 y/o tall, thin healthy male c/o sudden onset L sided CP with shortness of breath. The pain started while he was inhaling on a marijuana cigarette. It hurts more to breathe. Vitals: HR 110, RR 28, BP 110/70, sPO2 96%

44 Chest Pain: What is it? 60 y/o male with a history of severe COPD c/o increasing shortness of today that is not relieved with his home inhalers. Vitals: HR 110, RR 28, BP 110/70, sPO2 90% Heart: distant, tachycardic and regular Lungs: diffuse wheezing, decreased breath sounds on the right

45 Pneumothorax Primary Spontaneous – occurs in people without clinically apparent lung disease More common in men Associated factors = tall, smoking, changes in ambient atmospheric pressure, genetics, MVP, Marfan’s syndrome Disruption of the alveolar-pleural barrier is thought to occur when a bleb or bulla ruptures into the pleural space

46 Pneumothorax Secondary Spontaneous – occur with known underlying pulmonary disease More common in men Associated with any underlying pulmonary disease including infection, ILD, neoplasms, COPD, asthma, etc… Weakening of the alveolar-pleural barrier occurs secondary to the underlying lung disease either from inflammation or development of bullae

47 Pneumothorax Iatrogenic
Complication of intubation or aggressive BVM, central line placement, or any endoscopic procedure involving the trachea or esophagus Consider in any stable patient with acute deterioration, hypoxia, or increased difficulty with ventilation

48 Tension Pneumothorax Positive intrapleural pressure causes compression of the mediastinum and the contralateral lung Pressure exceeding 15 to 20 mm Hg impairs venous return to the heart Leads to cardiovascular collapse if not treated immediately  this is a clinical diagnosis not a radiographic one!

49 Pneumothorax – Symptoms
Ipsilateral sharp CP Dyspnea Pleuritic pain Cough

50 Pneumothorax – Signs Sinus tachycardia Hyperresonance
Decreased breath sounds Unilateral enlargement of the hemithorax Splinting Hypoxia

51 Pneumothorax: Diagnosis
Clinically for tension PTX CXR Radiolucent band devoid of lung markings Inspiratory/expiratory views Lateral decubitus views in sick patients Supine CXR may have deep sulcus sign Thoracic ultrasound Chest CT

52 Pneumonthorax

53 Pneumothorax - Tension

54 Pneumothorax – Deep Sulcus Sign

55 Pneumothorax: Management
Tension – needle decompression Tube thoracostomy  F for air, 32F at least if fluid is present Observation – for PTX < 20% collapse Reabsorption Rate 1-2% per day 4-8% if on 100% NRB

56 Chest Pain: What is it? 60 y/o male complains of sudden onset tearing chest pain that went up into his jaw, through to his back, and then down into his abdomen. He also vomited once, is diaphoretic, and appears very anxious. Vitals: BP 190/120, HR 110, RR 22, sPO2 95%

57 Aortic Dissection Occurs more often in men older than 40
HTN is the most common risk factor Associated with cardiac surgery, bicuspid aortic valve, stimulant use, and trauma Age<40, associated with congenital heart disease, Marfan, Ehlers-Danlos, and giant cell arteritis 44% of pts with Marfan’s will develop an aortic dissection

58 Aortic Dissection Type A – 62% Type B – 38%
Involve the ascending aorta  more lethal Type B – 38% Do not involve the ascending aorta Pt more likely to be older, smoke, have chronic lung disease, HTN, or atherosclerosis

59 Aortic Dissection - Diagnosis
Labs – CBC, chem7, PT/PTT, type & cross, CK-MB, troponin ECG – exclude other dx, 15% may have ischemic changes  3% dissect back and most commonly involve the RCA, may have LVH or nonspecific ST or T wave changes CXR – abnormal in 80% but nonspecific findings

60 Aortic Dissection - Diagnosis
CT scan – test of choice TEE – limited by availability and operator Aortography – no longer the test of choice MRI – excellent test but limited by availability and instability of the patient

61 Aortic Dissection - Management
Opioids – decrease pain and sympathetic tone Beta blockers – esmolol and labetalol Decrease BP and HR to decrease shearing forces Should be started first unless the pt is bradycardic Nipride – vasodilator, used in conjunction with a beta blocker to maintain SBP

62 Aortic Dissection - Management
Hypotensive pts – measure BP in all 4 extremities to make sure it is real, IVF, blood, immediately to OR Type A  OR (27% mortality if treated surgically vs. 56% if treated medically) Type B uncomplicated – 10% mortality when treated medically (32% mortality if complicated)

63 Chest Pain – What is it? 22 y/o healthy male complains of chest and back pain after forcing himself to vomit. He states he had food stuck in his chest while eating at Mongolian BBQ and then forced himself to vomit for relief. He now says that his voice is hoarse, it hurts to breathe deep, and he is still very nauseated. He tried to drink some water, but this only intensified the pain. Vitals: HR 120 BP, 130/90, RR 25, sPO2 97%

64 Esophageal Rupture – Boerhaave’s
15% are spontaneous with the remainder being iatrogenic from endoscopy, NGT, ETT, combitube, foreign body… 90% of spontaneous ruptures occur in the distal esophagus DX – CXR, gastrograffin swallow, CT Management IV antibiotics NPO and likely NGT Surgery consult

65 Chest Pain: What is it? 26 y/o male c/o retrosternal, sharp CP, difficulty breathing, pain when breathing deeply, and worsening dyspnea tonight when he laid down to sleep. He states that for the last week he has had URI symptoms and low grade fever, but now feels that it has moved into his chest with the increasing pain and difficulty breathing. Vitals: HR 110, BP 110/80, RR 24, sPO2 98% Heart: Tachycardic and regular, (+) pericardial rub Lungs: CTA Bedside TTE is negative for effusion

66 Pericarditis

67 Pericarditis Causes – infectious, injury/trauma, metabolic, systemic (RA), carcinoma, or aortic dissection DX – clinical suspicion, ECG, echo Echo – pericardial effusion and tamponade are worrisome complications  pts should be put in obs or hospitalized Treatment – NSAIDS, steroids for pts who cannot tolerate NSAIDS


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