Chest Pain [Read-Only] - University Of Washington
![Chest Pain [Read-Only] - University Of Washington](/img2/57/chest-pain.webp)
Objectives Discuss a ggeneral approachppto chest ppainEM Clerkship:Chest Pain Review differential diagnosis Develop an understanding of the diagnosis andmanagement of common and serious causes ofchest painBackgroundGeneral Approach Chest ppain is chief complaintpin 3% of ED ppatients Approachppall chest ppain ppatients as havingg a seriouscause until proven otherwise Diagnostic possibilities range from life-threatening tocommon or unusual H&PH&P, diagnostic testing and treatment should proceed inparallel given range of possible conditions Cardiovascular disease remains the #1 killer ofAmerican men and women Immediate visualization and rapid evaluation Stabilize and treat prior to full evaluationGeneral Approach Screen for severity–––––––ABCsIV access (& labs)OxygenMonitor, full VS /- EKG, portable CXRBrief H&PImmediate treatment Asa, TNG, Morphine, etc*– Monitor response to interventions12 Lead EKG Indications Chest ppainSymptomatic rhythmdisturbance (tachy, brady,palpitations,pp, etc ))SyncopeSOB, DOE, orthopnea or PND( 40 yo) Epigastricpgppain,, N/V ( ( 40 yyo)) Arm, neck or jaw pain ( 40 yo)Toxic ingestionAltered mental statusDizziness, hypotensionWhen in doubt
Portable CXR Rapidp evaluation for:– Pneumothorax– Pulmonary edema– Pneumomediastinum– Pneumonia– CardiomegalyC– Pacemaker lead position– DissectionOther testing Considerations in workingg upp chest ppain:– Cardiac enzymes– D-Dimer– BNP– CT scan– EchocardiogramHistorical FactorsPhysical Exam Position Aggravating/Alleviatinggggg factors* Quality* Associated symptoms* Radiation* Similarity to prior episodes Severity Cardiac risk factors*factors Timing* PMH/PSH MedicationsReproducible pain does not rule out serious causes of chest painDifferential Diagnosis What are serious causes of chest pain?p– Myocardial infarction– Unstable angina– PulmonaryP lembolismb li– Aortic dissection– Esophageal rupture– Pneumomediastinum– Spontaneous pneumothoraxVitals *General appearance/colorDiaphoresisNeck *Chest*AbdomenExtremities*Differential Diagnosis What are other causes ofchest pain?– Stable angina– Pericarditis– Abdominal pathology GERD/PUD Biliary obstruction Pancreatitis– Pneumonia/otherinfections– Herpes zoster– Chest wall ppain Muscle strain/tear Rib fracture/contusion-- Anxiety
Case 1 51M c/o acute onset L CP x 30 min,, diaphoresispno radiationno SOBno N/Vno syncopeno hx off samePMH: HTN, on no meds, NKDASH: tobacco tobacco, no drugsFH: HTNInitial Management ABCsIV, O2, monitor, full VS (bilateral BP’s)EKGpCXRLabs:CBC, M7, Coags, Cardiac enzymes ACTIONS?Case 1 Afebrile, 65 ((regular),g) 150/90 ((symetric),y) 18, 100% raLooks sweaty, distressed, uncomfortableChest clear, heart regular without M/GAbdAbdomensoft,ft NT/ND,NT/ND BS No JVD, no edema, no rash; nonfocalRemainder of exam wnlCase 1 pCXR normal Actions?– Activate cath lab ASAP– ‘MONA’ : Asa 325 mg chew and swallowNitro sublingual q5 x3; drip as neededMorphine 4-8 mg IVOxygen (at least 2L NC)– Heparin bolus & drip– Consider plavix (per institution protocol)– 2b3a2b3 inhibitors?i hibit ? to cath lab (consider tPA if cath lab unavailable)Case 1 Same ppresentation,, but EKG is normal Now what?– repeatt EKG @ 20 minsi &/&/or paini ffree– All normal / unchanged Cardiac enzymes return negative Now what?– ‘Risk stratification’
‘RiskRisk Stratification’Stratification Serial EKGs– “one EKG begets another” Serial cardiac enzymes– Intervals vary by risk factors and provider Stress testing– Nuclear stress, stress echo, EKG treadmill Angiography Cardiac CT?EKG Findings: ACS Infarction– 50% of acute infarcts will have ST elevation– Frequently nonspecific/subtle changes IschemiaI h i– 50% will have abnormal EKG Arrhythmia Normal or unchanged* Sensitivity of initial EKG in patients with ischemia is 2050%Spectrum of ACS Myocardialyinfarction– STEMI (EKG dx)– NSTEMI (troponin dx) Unstable angina (clinical dx) Stable angina (clinical dx) Undifferentiatedffchest pain (most(ED pts)) Reproducible pain or response to therapy does not ruleout serious causes of chest painCocaine Chest Pain The Problem Cocaine:––––accelerates atherosclerosisvasospastic (elevates BP and HR)pro-thromboticpro-arrhythmic The Solution:––––Cocaine CP EKGAssume ischemia until proven otherwiseTreat as if ACS*Treat pain with benzodiazepinesInitial ManagementCase 2 60M p/w sudden, ‘tearing’ SSCP radiating thru to backmaximali l att onsett N/V & diaphoresisno syncope or SOBLooks sweaty, distressed and very uncomfortablePMH: HTN,, no meds,, NKDASH: Moderate etoh, tobacco, no ilicitsFH: Adopted ACTIONS? ABCs IV,IV O2,O2 monitor,it fullf ll VS (bilateral(bil t l BP’s)BP’ )– 190/105; 165/85 EKG pCXR Labs:CBC, M7, Coags, Cardiac enzymes
Case 2 Afebrile,, 190/105,, 50,, 18,, 99%RALooks sweaty, distressedChest clear, heart regular with diastolic murmurAbdomen soft, NT/ND, BS No JVD, no edema, no rash; nonfocalRemainder off exam normalCXR: Aortic Dissection Normal (16%)* Wide mediastinumWiddi ti(60%)* Abnormal aortic knob /Left aortic cap Tracheal deviation EEsophogealhlddeviationi ti Ring sign (aortadisplaced 5 mm fromcalcififed aortic intima)EKG: Aortic Dissection Normal ( 1/3) Nonspecific ST or TT-wavewave changes (43%)*(43%)– LVH ( 1/3) from longstanding HTN STE (5%)*Action!!!:: Aortic DissectionAction!!! BP & rate control (dP/dt) goal SBP 100-120, HR 60-70– Labetalol,Labetalol esmolol– Nitroprusside nitroglycerin Pain control blunt adrenergic surge STAT imaging– CTA aortic dissection protocol – test of choice– MRA aortic dissection protocol– TEE Disposition– ICUC ffor medical management vs. definitivefsurgical repair
Aortic DissectionHistorical features*: Abrupt or sudden onset (87%) Ripping or tearing (54%) Chest pain (76%) Syncopeyp ((14%))AFindings*: BP asymetry 20 mm Hg(PPV for AD 98%) Asymetrical pulses (32%) New diastolic murmur: AI (51%) Tamponade (6%) Neurologic deficits (16%)Case 3 25F c/o sharp,p, stabbingg SSCP for the ppast 3 daysynon-radiatingnon-pleuriticworse with lying down, improved by sitting forwardrecent URI Sx with low grade feverPMH LMP 2 weeksPMH:k ago, NNo MMeds,d NKDASH: etoh, No TOB or IVDUFH: Denies ACTIONS?Initial evaluation A37.4, 94, 124/78, 16, 98% RAAppears comfortable, sitting forwardClear breath soundsRRegularl rhythm,h th no murmurIt sounds a bit “funny” over the left sternal borderRemainder of exam wnlInitial management ABCsIV, O2, Monitor, Full VSEKGCXRLabs:CBC, M7, B-HCGB
Case 4 PericarditisWhat if this were the EKG? Common etiologygy idiopathicpor infectious Other causes:malignancy, SLE, RA, medications, radiation Dressler’s syndrome late post-MI Actions––––CXR: normalWBC 12,000, Cr and Trop wnlDiagnosis?Actions?NSAIDs: Toradol or IbuprofenSteroids if cannot tolerate or failed NSAIDsEchocardiogramAdmit if hx ESRD,ESRD TBTB, recent MIMI, anticoagulatedanticoagulated,Immunosuppressed, or if patient looks unwell enlarged, “bottleshaped” heart
Case 5: A ppicture is worth 1000 words Then you finish your exam 45M c/o “burninggppain” on L chest for 6 daysyNon-radiating“A little short of breath” because of the painNNeverhhadd paini liklike thithis bbeforef 37.1, 78, 130/80, 18, 98% RAWell-appearingClear breath soundsRegular rhythm, no murmurAbdomen soft, non-tenderExtremities warmwarm, no edemaTake home points Vesicular lesions Chest ppain is serious until pproven otherwise Erythematous base H&P, diagnostic testing and interventions shouldproceed in parallel Dermatomal distribution Stabilize and treat prior to full evaluation Consider the spectrum of disease and risk-stratifyrisk stratify forfurther testing and disposition
Chest Pain Objectives Discuss a ggpp peneral approach to chest pain Review differential diagnosis Develop an understanding of the diagnosis and management of common and serious causes ofmanagement of common and serious causes of chest pain Background Chest
Chest Pain 4. Introduction 4.1. ESSENTIALS Chest pain complaints are of common occurrence in medical practice. Chest pain frightens the patient and puts the physician on the alert, as it is often a symptom of a serious disease. From the diagnostic standpoint, chest pain may present a real challenge to the physician.
pain”, “more pain” and “the most pain possible”. Slightly older children can also say how much they are hurting by rating their pain on a 0-10 (or 0-100) scale. Zero is no pain and 10 (or 100) is the worst possible pain. What a child is doing Often children show their pain by crying, making a “pain” face, or by holding or rubbing .
Short-term pain, such as when you suffer a sprained ankle, is called 'acute' pain. Long-term pain, such as back pain that persists for months or years, is called 'chronic' pain. Pain that comes and goes, like a headache, is called 'recurrent' pain. It is not unusual to have more than one sort of pain or to have pain in several places
General discussions of pain often refer simply to three types: 1) Acute (brief that subsides as healing takes place) 2) Cancer 3) Chronic non-malignant pain - "persistent pain" Classification of pain by inferred pathology: 1) Nociceptive Pain 2) Neuropathic Pain (McCaffery & Pasero, 1999) Nociceptive Pain A. Somatic Pain B. Visceral Pain
Knee Pain 1 Knee Pain 2 Knee Pain 3 Knee Pain 4 Knee Pain 5 Lateral Knee Pain Medial Knee Pain Patella Pain 1 Patella Pain 2 Shin Splint. 7 Section 6 Ankle/Foot Big Toe 89 . For additional support, wrap another tape around the last finger joint. Step 3. No stretch is applied during application. 30 Step 1 Step 2 Finger Pain. 31 Requires;
CT Chest Asbestosis (High Resolution) Fibrosis CT Chest Without CT Chest Without Contrast --- HIGH RESOLUTION 71250 Contrast Lung Cancer Screening (Low Dose Protocol) CT Chest Without Contrast 71250 CTA Chest (PE Study) Chest Pain/Dyspnea DVT Tachypnea Hemoptysis Shortness of Bre
The assessment and management of chest pain in primary care A focus on acute coronary syndrome Richard Thomsett, Louise Cullen Background Chest pain is a common presentation and diagnosis can be challenging. There are many causes for chest pain, including life-threatening conditions s
health and care services should be delivering standards of care, and health outcomes, for prisoners that are at least equivalent to that of the general population. Doing so involves identifying and addressing health and care needs, which may have gone unrecognised, and supporting prisoners to lead purposeful, healthier lives. We recommend that: the National Prison Healthcare Board work .
