Critical amp Emergency medicine 1 st lecture Second year student Dr Warda Ramadan Lecturer of critical care and Emergency Nursing ID: 1043204
Download Presentation The PPT/PDF document "Acute chest pain" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
1. Acute chest pain Critical & Emergency medicine (1st lecture) Second year student Dr. Warda RamadanLecturer of critical care and Emergency Nursing
2. Outlines: Definition of Acute Chest painLife-threatening causes of chest painDifferential diagnosisTypical vs. Atypical Chest PainAssessment of chest painExamples and causes of chest pain: Unstable angina MYOCARDIAL INFARCTION Pulmonary embolism pericarditis
3. Acute Chest painis an imprecise term. It is often used to describe any pain, pressure, squeezing, choking, numbness or any other discomfort in the chestChest pain has many possible causes, all of which deserve medical attention. The causes of chest pain fall into two major categories — cardiac and non cardiac causes.
4. Life-threatening causes of chest painAcute coronary syndrome (unstable angina, NSTEMI, STEMI)Aortic dissectionPulmonary embolismPneumothorax (Tension pneumothorax)Pericardial tamponadeMediastinitis (e.g. esophageal rupture)
5. Differential diagnosisUpToDate 2012
6. Typical vs. Atypical Chest Pain TypicalCharacterized as discomfort/pressure rather than painTime duration >2 minsProvoked by activity/exerciseRadiation (i.e. arms, jaw)Does not change with respiration/positionAssociated with diaphoresis/nauseaRelieved by rest/nitroglycerinAtypicalPain that can be localized with one fingerConstant pain lasting for daysFleeting pains lasting for a few secondsPain reproduced by movement/palpation
7. Assessment of chest pain .N Normal: what was before this symptom develop?O Onset : when start? What day &time? Suddenly or gradually?P Precipitating & palliative factors: as stress, position, and what can relieve it?Q Quality & quantity: how does it feel? Is more/less than before?R Region & radiation: where it occur? Does it radiate to other region?S Severity: Numerical pain scale of 0 to 10.T Time: how long it last? Does it occur with anything as before, during, or after meals?
8. 1- Unstable angina and non -st –segment- elevation myocardial infraction: Signs and symptoms:Typical Chest pain which radiate to the neck, jaw, shoulders, and inner aspects of the upper arms, usually the left arm. shortness of breath Pallor, Diaphoresis, Dizziness Nausea and vomiting. Anxiety.
9. Diagnosis testes:Patient history of chest painThe 12-lead ECG :Cardiac biomarkers (A cardiac-specific troponin)In Unstable angina: ECG and Cardiac biomarkers show no evidenceIn NSTEMI: the pt has mild elevated cardiac biomarkers but no definite ECG exercise stress testing.ECOMagnetic resonance imaging (MRI).Coronary angiography. Is the definitive tool to diagnosis CADUnstable angina and non -st –segment- elevation myocardial infraction
10. Treatment:1. Oxygen therapy: to increase amount of o2 to myocardiam2-antiplatelet (aspirin): 1-4 tablets of 325mg taken daily.3-Beta blockers (should have administered intravenously). Beta blockers used to decrease myocardial oxygen consumption by reducing myocardial contractility, sinus node rate, and atrioventricular (AV) node conduction velocity.3-Nitro-glycerine: (vasodilator) If three sublingual tablets (0.4 mg) does not relieve the pain of angina, intravenous (IV) nitro-glycerine may be useful. 4 - Morphine sulphate:Morphine beginning with 2 mg intravenously should be administered if nitroglycerin does not relief of pain.5- Thrombolytic therapy: (streptokinase, urokinase ).6- Anticoagulation:Intravenous unfractionated heparin can be administered.Unstable angina and non -st –segment- elevation myocardial infraction
11. Acute myocardial infraction with st –segment elevation:Symptoms:Typical chest pain with or without radiation to the left arm, shoulder, or jaw. lasts from 10–15 minutes to several hours. poorly responsive to nitro-glycerine and may require morphine for relief. Diaphoresis, syncope, Diagnosis testes:Patient history of chest painThe 12-lead ECG : which show st- segment elevation occurs within minutes and may last for up to 2 weeksCardiac biomarkerscreatine kinase (CK): rise within 4 to 6 hrs , Myoglobin (rise within 2hrs). Highly specific Troponin (I, and T): rise within 4 to 6 hrsECO:.Coronary angiography
12. Treatment:Medical management in emergency for STEMI: As previous in US & NSTEMI PLUS:Resore coronary perfusion: in those presenting less than 12 hr after symptoms onset which include:Primary percutaneous coronary intervention (PCI): IF available this technique includes remove of thrombus, dilation of coronary arteries by balloon (coronary angioplast), insert stent and atherectomyIf PCI un available: fibrinolytic therapy, its used to establish reperfusion and lyse coronary thrombi by converting plasmiogen (fibrinogen) to (fibrin) plasminSedation: Sedatives such as intravenous or oral benzodiazepines may be useful in reducing the level of anxiety.Beta-adrenergic blockade: β-adrenergic blockade intravenou should be accomplished after the diagnosis of acute myocardial infarction Acute myocardial infraction with st –segment elevation:
13. 3- Pulmonary embolism: obstruction of the pulmonary artery or one of its branches by a thrombus (or thrombi).Clinical manifestations: typically sudden in onset Dyspnoea,TachypnoeaChest pain of a pleuritic nature (worsened by breathing), Anxiety, Fever,Tachycardia, Cough and hemoptysis , diaphoresis, Syncope.
14. Diagnostic studies:Chest radiograph :Usually normal , but may shows infiltrates , atelectasis, Or a pleural effusion.ECG : Shows sinus tachycardia , PR interval depression ,and nonspecific T wave changes ,T wave inversion in leads V1 , V2 .ABG:Shows hypoxemia and hypocapnia, however, ABG measurements are normal in up to 20 % of patients with PE .Ventilation – perfusion scan:Pulmonary angiography.D-dimer: a small protein fragment present in the blood after a blood clot is degraded by fibrinolysisManagement:Nasal oxygen is administered immediately to relieve hypoxemia, and central cyanosis.Hypotension is treated by a slow infusion of dobutamine or dopamine.Anticoagulation Therapy: Heparin is used to prevent recurrence of emboli.Warfarin sodium (Coumadin) administration is begun within 24 hours after the start of heparin therapy.Thrombolytic Therapy: (urokinase, streptokinase,) resolves the thrombi or emboli more quickly, reduce pulmonary hypertension, and improving perfusion, oxygenation, and cardiac output.3- Pulmonary embolism
15. 4- Pericarditis:Pericarditis is inflammation of the pericardium. Acute pericarditis is pericarditis that lasts no longer than 1 or 2 weeks. Inflammation often involves the adjoining diaphragm.Pericarditis can be a primary disease or occur secondarily as the result of some other disorder, such as acute MI or renal failureCausesIdiopathic or unknown (usually presumed to be viral)• Infectious OR • Bacterial• Tuberculosis• Autoimmune or inflammatory• Systemic lupus erythematosus• some Drugs and Vaccinations• Radiation therapy• Following device implantation, such as an implantable defibrillator• Acute myocardial infarction• Trauma to the chest wall or myocardium, including cardiopulmonary surgeryChronic renal failure requiring dialysis
16. Pericarditis Diagnosis:Medical history focuses on chest pain: Does the pain get worse when pt take a deep breath? Is it worse when pt lie down? Does it get better after pt sit up and lean forward?Physical examination focuses on careful listening through a stethoscope for the scratchy sounds called a pericardial rub, which are produced by heart muscle rubbing against the inflamed pericardium. These sounds strongly suggest the diagnosis of pericarditisECG.Note the diffuse upward concavity ST changes and the PR-segment depression.
17. Symptoms:Chest pain. The pain is felt below the sternum, and below the ribs on the left side of the chest.Pericardial effusion: fluid accumulate between the pericardium and the heart Dyspnea.Distended veins in the neck Swollen ankles and feet.Treatment:anti-inflammatory agents. Aspirin prescribed as initial therapy. nonsteroidal anti-inflammatory drugs (NSAIDs) agents are prescribed. (ibuprofen, and naproxen) ,NSAIDs are usually quite effective in reducing inflammation and eliminating the pain associated with pericarditis.Pericardiocentisis, a thin hollow needle is carefully inserted through the chest wall into the area of accumulated fluid, and the fluid is drained through the needle.4- Pericarditis
18. 5- coronary spasm:Coronary artery spasm is a temporary, sudden narrowing of one of the coronary arteries.Causes:Alcohol withdrawal Emotional stress Exposure to cold Medications that cause narrowing of the blood vessels (vasoconstriction) Symptomes: chest pain occurs at rest , Lasts from 5 to 30 minutes .Exams and Tests:Tests to diagnose coronary artery spasm may include:Coronary angiography ECG Treatment: - nitro-glycerine can relieve pain. -calcium channel blockers. -Beta-blockers.
19. 6-pleurisy:Inflammation of pleura. Causes:Viral infection Bacterial infection Pneumonia Tuberculosis Pulmonary embolus Symptoms:Pain in the muscles of the chest Persistent cough Fever General malaise.
20. Diagnosis methods:Physical examination - using a stethoscope, the doctor can hear the pleura scraping against each other. Other breath sound abnormalities that suggest pleurisy include rattling or crackling. Blood tests - to determine whether the cause is viral or bacterial. X-rays - of the chest, including CT scans or other imaging scans using ultrasound. Thoracentesis - a small sample of pleural fluid is removed and examined. Bronchoscopy - a thin tube is inserted down the windpipe to examine the airways.Treatment:Treating the underlying cause - for example, treatment for tuberculosis Medications such as antibiotics and anti-inflammatory drugs Sedatives to relief the pain.Draining off the excess fluid - in the case of pleural effusion. 6-pleurisy
21. 7- Costochondritis:Inflammation of the cartilages of the ribcage. Symptoms:Pain: may have a sudden or gradual onset, and may be mild or severe,tenderness, swelling occur in one or more of the 4 upper ribs. Diagnosis of Costochondritis:The medical history and physical examination are usually sufficient for diagnosis. Treatment: local heat, analgesics, anti-inflammatory drugs, or local steroid injections.
22. 8-Acute cholecystitis:a sudden inflammation of the gallbladder that causes severe abdominal pain and which can radiated to chest CausesIn 90% of cases, acute cholecystitis is caused by gallstones in the gallbladder, and tumors of the gallbladder may also cause cholecystitis.SymptomsThe main symptom is abdominal pain that is located on the upper right side or upper middle of the abdomen.Abdominal fullness Fever Nausea and vomiting Yellowing of skin and whites of the eyes .
23. Exams and TestsA physical exam will show that abdomen is tender to the touch.following blood tests are ordered :Amylase and lipase Bilirubin Complete blood count ( CBC) -- may show a higher than normal white blood cell count Liver function tests Imaging tests that can show gallstones or inflammation include: Abdominal ultrasound Abdominal CT scan Abdominal x-ray Oral cholecystogram Gallbladder radionuclide scan Treatment:Intravenous fluids, and antibiotics to fight infection.-surgery to remove the gallbladder is usually needed when inflammation continues or recurs. - low-fat diet
24. Nursing roles for patients with chest painBed rest for a minimum of 12 to 24 hours Obtain 12-lead electrocardiogram (ECG) during chest pain to be read within10 minutes.Start oxygen therapy Obtain laboratory blood specimens of cardiac biomarkers, including Troponin. Minimize the number of times the patient’s skin is punctured andAvoid intramuscular injections Draw blood for laboratory tests when starting the IV line Start IV lines before thrombolytic therapy; designate one line to use for blood draws Avoid continual use of noninvasive blood pressure cuff Monitor for acute Dysrhythmias and hypotension Monitor for reperfusion: resolution of angina or acute ST segment changes
25. Nursing roles for patients with chest painCheck for signs and symptoms of bleeding: decrease in hematocrit and hemoglobin values, decrease in blood pressure, increase in heart rate, oozing or bulging at invasive procedure sites, back pain, muscle weakness, changes in level of consciousness, complaints of headache Treat major bleeding by discontinuing thrombolytic therapy and any anticoagulants; apply direct pressure and notify the physician immediately, treat minor bleeding by applying direct pressure if accessible and appropriate; continue to monitor Evaluate for indications for reperfusion therapy:
26.