chestpain.ppt

Chest PainZhou YunThe Affiliated Hospital of Medical College of Ningbo UniversityEmergency DepartmentChest PainCardiovascular disease is the 1st cause of death in the United States5.4%of all visits to the ED are for chest pain2.5%of patients with an acute myocardial infarction(AMI)are sent home 20%of all ED malpractice claims are for misdiagnosed chest pain complaints.Be difficult to diagnoseChest PainWhy the diseases of different organ systems present with similar symptoms?Visceral painSomatic pain3Visceral PainSensory nerves from internal organs enter the spinal cord at multiple levels and thus the pain is difficult to describe and localizeAchingPressureHeavinessSomatic PainSensory nerves from these structures enter the spinal cord at specific levels and the pain is easily described and localizedSharp,stabbingPatients will point to an area of well localized painBone,skin,muscle,parietal pleuraCauses of chest painCardiovascularA.C.S.(Acute Coronary syndrome)PericarditisAortic dissectionAortic stenosisPulmonaryPulmonary embolismPleurisyPneumothoraxPneumoniaPediatricsKawasaki diseaseHypertrophic cardiomyopathyCongenital heart diseaseGastrointestinalEsophageal refluxEsophageal spasmEsophageal rupturePeptic ulcer diseaseGallbladder diseasePancreatitisChest Wall PainHerpes ZosterCostochondritisCervical radiculopathyRib fractureAnxietyEvaluation of Chest PainGOALEarly detection and safe management of life-threatening diseasesComplete history is very importantTimely and appropriate testingDo not focus on a benign disease and miss a life-threatening illness8Evaluation of chest painMaintain a high index of suspicion for life-threatening illness Rapid triage Is the patient at risk for serious illness?Abnormal vitals signsPatient looks sick,diaphoretic,short of breath,altered level of consciousness.Risk factors or history of cardiovascular diseaseCardiac monitor,IV,oxygenEKG within 10 minutes of patient arrivalHistoryComplete history most importantFocus on the characteristics of the pain,associated symptoms,risk factors,and history of cardiovascular diseasePain scale 1-101-no pain10-worst possible painHistoryDuration of the painPain lasting seconds probably not cardiacConstant pain for longer than 8-12 hours with negative workup probably not cardiacIntensity of painImmediate onset of severe pain Aortic dissectionPain reaches maximum intensity gradually ACS(Acute Coronary syndrome)HistoryQuality of the painBurning pain GastrointestinalTearing pain Aortic dissectionSharp,stabbing pain Usually not ischemicUp to 20%of patients with AMI describe pain as sharpBe worse with breathing or coughingPleuritic pain-Lung,musculoskeletal,pericardialPleuritic chest pain is described in up to 6%of MI patients.HistoryQuality of the painLocalized pain reproduced by movement or palpation of the affected areaChest wall painVisceral pain radiates to the jaw,arms,and neckACSShortness of breathNausea&VomitingDiaphoresisfatiguepalpitationsRisk factorsAge 40MalePost-menopausal femaleHypertensionHyperlipidemiaCigarette smokingDiabetesFamily historyObesityDrug abuseCocaineThe absence of risk factors does not rule out cardiac disease14Acute Coronary Syndrome(ACS)Unstable AnginaNew onset of symptomsSymptoms that occur at restA change in the patients usual pattern of anginaNo ST elevation,no elevation of cardiac enzymesEKG will be normal about 50%of patientsEvidence of ischemia-ST depression or T-wave inversionACSAcute Myocardial InfarctionSTEMIST elevation of 1 mm in at least 2 contiguous leads Elevated cardiac enzymesNon-STEMIST depression and T wave inversionNew left bundle branch block or Q wavesElevation of cardiac enzymesSTEMI-ST elevation MINon-STEMIAnginal EquivalentsAtypical Chest PainUp to 33%of ACS will not have chest painDyspnea with exertion or at restShoulder,arm,or jaw pain onlyNauseaLightheaded,dizzy,or syncopeGeneralized weaknessDiaphoresisAcute change in mental statusPalpitationsEKGThe best test to rapidly diagnose an acute MIObtain within 10 minutes of patients arrival Up to 50%of initial EKGS will be normal or have non-diagnostic changesSerial EKGSBiomarkersTroponin T and IPreferred markerProtein located in cardiac musclePoor sensitivity first 6 hours after onset of symptomsRepeat in 8-12 hours after onset of symptomsCan be elevated withPulmonary embolismAortic dissectionRenal failureSepsisCardiac trauma or surgeryCHF(Chronic heart failure)BiomarkersCPKLocated in cardiac and skeletal muscleCPK/MB is the cardiac isoenzymePoor sensitivity first 6 hours after onset of symptomsRepeat testing in 8-12 hoursUseful in detecting reinfarctionMyoglobinFound in skeletal and cardiac muscleGood sensitivity early after onset of symptomsbut poor specificityBiomarkersTest/PeriodOnsetPeak DurationCPK/MB3-12 hours 18-24 hours36-48 hoursTroponin3-12 hours 18-24 hoursUp to 10 daysMyoglobin1-4 hours6-7 hours 24 hoursNote:Repeat in 8-12 hoursPulmonary EmbolismMajority form in the deep veins of the pelvis and lower extremitiesSize of the clot will determine signs and symptomsLarge clots can cause syncope,abnormal vitals,sudden deathPulmonary EmbolismRisk factorsPrevious DVT(Deep Vein Thrombosis)or PEPregnancyCancerRecent surgeryProlonged bed restAge50SmokingOral contraceptivesObesityInherited blood disordersPulmonary EmbolismSigns and symptomsDyspneaPleuritic chest painTachycardiaCoughHemoptysisFever rarely 39SyncopeEvidence of DVT in the extremitiesPulmonary EmbolismEKGSinus tachycardiaNon-specific ST and T wave changesRight heart strain pattern RBBB(Right bundle branch block)Chest x-rayUsually normal or non-specific changesArterial blood gas(ABG)Not useful in the diagnosis of a PECan have a normal PO2 and A-a gradient with PEPulmonary EmbolismD-DimerFibrin degradation productTest sensitivity 95%,specificity low 50%What can elevate the D-DimerPregnancyCancerTraumaRecent surgeryDisseminated intravascular coagulation(DIC)Pulmonary EmbolismHigh risk patientsDo not obtain a D-Dimer immediately to go other testingCT ScanV/Q ScanPulmonary angiogramPericarditisInflammation of the cardiac pericardiumPain is due to irritation of the parietal pleuraSharp pleuritic substernal painRadiates to the back,neck,or shoulderWorse with cough,inspiration,supineImproves with leaning forwardPericardial friction rub,tachycardia,dyspneaEKGDiffuse ST elevationTroponin is elevated in up to 22%Pericarditis EKGSpontaneous PneumothoraxSudden rupture of a lung blebTall thin males age 20-40Underlying lung diseaseSmokersSudden onset of sharp pain,worse with inspiration,and SOB(shortness of breath)Physical examDecreased breath sounds on the affected sideTension pneumothorax-Immediate life threatDecreased venous return to the heartSevere respiratory distress,tachycardia,hypotensionPneumothoraxTension PneumothoraxAortic DissectionStarts as a tear in the intima of the aorta that spreads through the medial wall under elevated systolic aortic pressureMortality untreated28%in 24 hours50%in 48 hours70%in one week Risk factorsHypertensionPregnancyLupus,syphilis,endocarditisMarfans diseaseAortic DissectionHistorySudden onset of sharp,tearing,maximal painPain radiates to the neck or backAortic DissectionPhysical examMajority will be hypertensiveDifference in blood pressure between armsMurmur of aortic regurgitation Neurologic deficitsChest pain with neurologic deficit,THINK DISSECTIONEKG-useful to rule in or out MIChest X-rayWidened mediastinumRule out other etiologiesGastrointestinal Etiology in up to 40%of chest pain complaintsDifficult to discern from ACSPain described as burning,pressure,or dullAcid RefluxSubsternal,epigastric burning painPain worse with alcohol,caffeine,certain foodsWorse supine and in the morningRelieved with antacidsGastrointestinalEsophageal spasmOften associated with reflux diseaseDull,pressure,substernal pain lasting for hoursCan be relieved with NitroglycerinNTG(nitroglycerin)relaxes smooth musclesPain relief with NTG NOT diagnostic of ACSPeptic ulcer diseasePancreatitis and gallbladder diseaseInclude lipase and liver function tests in your workupBoerhaaves SyndromeForceful vomiting after excessive eating and drinking causes esophageal rupture.Mediastinal contamination of stomach contentsSudden onset of severe pain radiating to the backMortality is 10-50%and directly related to the delay in making the diagnosis and initiating treatmentBoerhaaves SyndromeChest Wall PainThe cause in up to 30%of ED visitsWell localized,sharp,positional painReproducible by palpating a specific area of the chest wallCostochondritisPain and tenderness at the costochondral or costosternal jointsTreatmentsRestHeatNSAID(non-steroidal anti-inflammatory drug)Mental IllnessThe cause in up to 10%of ED visitsPatients are with vague symptoms and historyHyperventilation can cause non-specific ST-T wave changesA diagnosis of exclusionChest PainCervical disc diseaseNerve root compression causes chest painHerpes ZosterSharp burning pain before the rashPain and herpetic rash in a dermatome distributionHerpes ZosterThank You