Acute Chest Pain Dr.S.R.Pahlavanpoor - PowerPoint Presentation

Slide1

Acute Chest Pain

Dr.S.R.Pahlavanpoor

EMS Chief Manager

Slide2

Perspective&Epidemiolgy

.More than

5

milion

patient to the ED each year with complaints of chest

pain;this

represents nearly

5%

of all patients seen in the ED in the

US.

Slide3

Perspective&Epidemiolgy

.Critical

Dx

causing chest pain:

.

ACS

:most

significant potential

Dx

in the ED

.Aortic dissection

.Pulmonary embolus

.

Pneumothorax

.

Pericarditis

with

tamponad

.Esophageal rupture

Slide4

1-Rapid assessment and stabilization

A-

all patients except those with obvious benign cause of CP are transported as promptly as possible to the treatment area

B-

cardiac

manitor

- oxygen therapy-IV line-and assessing patients appearance and V/S

C-

if the patient shows

sign&symptoms

of

Tension

Pneumothorax

(CP-RD-Shock-Unilateral reduction or absence of breath sound)need to

immediate

intervention(needle/tube

thoracostomy

)

Slide5

1-Rapid assessment and stabilization

D-

Check V/S:

.if V/S derangement and patient symptomatic:

TREATED as APPROPRIATE

.if V/S are stable

brief

Hx

and P/E

are performed

E-

ECG-CXR

ECG performed in all patients with CP includes all patients

30 Yr old and older

CXR performed for patients with serious cause of CP

Slide6

1-Rapid assessment and stabilization

F-

Laboratory test

G-

Confirm of

Dx

& Treatment

Slide7

ACS(acute coronary syndrom

)

Spectrum of clinical presentation result from common

pathophysiology

of

Myocardial

ischemia and Necrosis

Include from

asymptomatic

CADand

STABLE ANGINA to UNSTABLE ANGINA and AMI and SUDDEN CARDIAC DEATH.

Slide8

STABLE ANGINA

TRANSIENT Episode of CP or Discomfort that typically reproducible with frequency of attack

constant over time

.

1- Classical

Hx

:

a:character

:pain or discomfort with ;

pressure ;or heaviness;

sensation

b:location

:

substernal or

precordial

radiate to neck-jaw-arm

Slide9

STABLE ANGINA

Location and radiation typically in left side of chest but sensate in both side or only in right side.

c:duration

:last from

2-5 minutes up to 20

minutes

d:exacerbation with exertion-heavy meal-stress-cold

Alleviation by rest

Slide10

Angina Equivalent Symptom

Arise alone(Atypical

Hx

) or in combination with angina and include:

Dyspnea

-nausea-vomiting-diaphoresis-weakness-dizziness-excessive fatigue-

anexiety

.compliant of

GASand

INDIGESTION or HEARTBURN in the absence of known

Gereflux

or Reproducible pain upon abdominal palpation should rise suspicion of ACS

Slide11

STABLE ANGINA

2- Atypical

Hx

:

a:

atypical features in character(

pluritic

-positional-reproducible by palpation)-duration-location and exacerbating factor

b:

presence of AES alone

c:

common seen in DM-Older age-Female gender-Dementia ……

Slide12

STABLE ANGINA

d:

in older age(>85Yr):

Stroke-weakness-AMS-are more common than CP.

e:

in patient with DM:

Atypically

sympton

are common

(

dyspnea

-nausea and vomiting-

cofusion

- fatigue

)

f:

in Female

gender:high

risk of AMI without CP

Common

symptom:

dyspnea

-indigestion-weakness-unusual fatigue-cold sweat-sleep disturbance-

anexiety

-dizziness

Slide13

UNSTABLE ANGINA

New – onset angina

Angina at rest or occurring with minimal exertion

Worsening change in previously STABLE ANGINA

(in frequency or duration of attack or resistance to previously effective medication)

Slide14

VARIANT ANGINA

Caused by coronary artery vasospasm at rest and it may be relieved by exercise or NTG

AMI:

Includ

combination of Clinical symptom-ECG change-

tupically

rise and fall in CK-MB and TROPONIN

Slide15

Aortic Dissection

Rapid

onset+sever

CP

Maximal at beginning

Radiate

anteriorly

in chest to the back

interscapular

area or into the abdomen

Pain often has a

TEARING

Neurologic complication of stroke-peripheral neuropathy-paresis or paraplegia-abdominal and extremity ischemia

Slide16

PULMONARY EMBOLISM

Pain often lateral-

pleuritic

Centerl

pain:massive

embolus

Abrupt in onset and maximal at beginning

May be episodic or intermittent

Dyspnea

(prominent role)

Cough-

Hemoptysis

(,20%)

Angina like pain(5%)

Slide17

ESOPHEGEAL RUPTURE

Pain usually preceded by vomiting

Abrupt onset

Pain is persistent and unrelieved

Localized along the esophagus

Increased by swallowing and neck flexion

Diaphoresis-

dyspnea

-shock

Slide18

PNEUMOTHORAX

Pain

uaually

acute and abrupt onset

Often lateral-

pleuritic

Central in

largs

pneumothorax

Dyspnea

-AMS-Shock

Slide19

PERICARDITIS

Dull and recurrent pain unrelated to exercise or meal

Sharp or

pleuritic

Not relieve by NTG

Dyspnea

-diaphoresis

Slide20

ECG in CP

ECG performed in all patients with CP includes all patients

30 Yr old and older

In ACS:ST segment change(

STdep

:./5mm-

(

STele

:./6-1mmor.1mm-Twave inversion>1mm

New LBBB

Seen normal or nonspecific ECG in

pateints

with ACS

Diffuse ST

ele

in

Pericarditis

Slide21

CXR in CP

Wide

mediastinum

in Acute Aortic Dissection

Mediastinal

Air Fluid level or

Pneumomediastinum

in Esophageal Rupture

Slide22

LAB test in CP

Serum D

dimer

may help discriminate patients with Pulmonary Embolus

CK-MB and

Troponin

(

IandT

)

when elevated identify with ACS who have the highest risk for complication.

Asignificant

increase (2-3 time from baseline)has been shown to be more sensitive than isolated measurements

ofany

enzyme

Single value of any enzyme can not be used to exclude ACS as a cause of pain

Slide23

TREATMENT

If cardiac cause is suspected and V/S is stabled pain relief with NTG(./4mg SL every 3-5 minutes for 3 dose+ Aspirin(81-325mg)is given and in patients with contraindication to Aspirin CLOPIDOGREL(loading dose 300mg) is given.

Slide24

PERICARDIAL TAMPONADE

Patient with

low

volage

in ECG-diffuse ST

ele

- elevated

jvp

-and sign of shock:

Confirm

Dx

by echo

cardiography

and treated by

Pericardiocentesis

.

Slide25

THE END

THANKS