Emergency Medicine- Chest Pain Ddx for Chest Pain: Trauma PE PTX Angina (CAD) Aortic Dissection/rupture Costochondritis

hondritis (chest wall pain) Pleurisy GERD Pericarditis, Myocarditis, Endocarditis

-If pain radiates from the chest to the shoulder think Phrenic Nerve -Patient with CP leaning forward Pericarditis EKG is the 1st thing you will get for a patient with Chest Pain* o Then ASA (maybe MONA) o cardiac enzymes (iSTAT=troponin only; fast) o CXR o Labs o Oxygen, cardiac monitoring, (defib pads if HR<50) Labs for CP: CBC BNP (Test for CHF) CMP PT/PTT/INR Troponin Drug Levels (i.e. Digoxin) 5 Main Risk Factors for CAD: 1. Tobacco use 2. HTN 3. Diabetes 4. Obesity 5. Drug abuse (especially cocaine) Elderly with CAD often present with SOB more than CP Women and Diabetics with CAD 1. Epigastric Pain 2. SOB 3. Lack of CP 4. Insomnia, Fatigue, N/V, back pain *Women/diabetics with CP and Back Pain think Aortic Dissection *Myocardial cells become ischemic after 10 seconds of coronary occlusion, but remain viable for 20 minutes under these conditions Stable Angina= CP that occurs with activity but goes away with cessation of activity - Vessels narrow and harden and cannot dilate upon exertion/stress (Reversible Ischemia) - S/Sxs: CP lasting 3-5 minutes, pallor, and dyspnea. May radiate to Jaw, neck, left arm/shoulder, or back. - Tx: Rest and Nitrates Unstable Angina= Acute new onset, occurs AT REST, or Increasing in severity or frequency - Rupture of a plaque in the Coronary Artery leading to thrombosis occlusion for 10-20 mins - S/Sxs: Tachycardia, S4 Murmur, Pulmonary Congestion, ST Depression on EKG, T-wave inversion, and Dyspnea. LVH and Cardiomegaly on CXR - Tx: Thrombolytics ASA, Clopidogrel, Heparin Bipass Surgery (maybe) S3 murmur = CHF

S4 murmur= MI MI (STEMI/NSTEMI) After 20 minutes of occlusion, myocardial cells die (necrosis) - Electrolytes are lost, fats released, blood sugars Increase, distant myocytes hypertrophy, and contractility decreases. - Most People die from Secondary Dysrhythmias (V Fib and V Tach) - S/Sxs: o CP o Radiation to jaw, neck, left arm (vagus or phrenic nerve) o N/V o Sweats, Cool skin (vasoconstriction) o Abnormal Heart Sounds o Elevated CPK-MB, Troponin 1, and T wave o EKG abnormalities - Tx: o ASA o Sublingual Nitro or Morphine Sulfate o PCI (cardiac cath) o Thrombolytics (tpA, urokinase, streptokinase) used when no cath lab present **Cardiogenic Shock IF CO is insufficient to maintain normal perfusion to organs P.E.A. (Pulseless Electrical Activity) Unresponsiveness and lack of palpable pulse in presence of organized cardiac electrical activity, often resulting in Acute Coronary Syndrome - An example of P.E.A. is a Pulmonary Embolism. Thrombolytic Therapy CAD patients with STEMI or new Left Bundle Branch Block presenting within 12 hours of Symptom onset. **PCI is preferred treatment for STEMI if door to cath< 90 minutes, otherwise use thrombolytics **Contraindications Bleeding disorders, recent surgery, on blood thinner, pregnant, Hx of HTN, active bleeding ***DO NOT give a Nitro if Inferior Wall MI (leads II, III, and avF)*** MIs Inferior Wall Leads II, II, and avF (RCA) Septal Wall V1 and V2 (LAD) Anterior Wall V3- V4 (LAD) (V1 and V2 somewhat too) Lateral Wall Leads I, avL, V5 and V6 (LAD and Circumflex) Posterior Wall V1-V3 (Circumflex) *V-Tach or V-Fib SHOCK! *SVT Give Adenosine If too Bradycardic, can go into CHF because of fluid back up and build up - Give Atropine and put pads on just in case Who gets what Meds? Aspirin ALL Plavix (Clopidogrel) Stents or CAD pts Coumadin Reserved for pts with Blood Clot or Pacer Praxada CAD or Stents; NOT REVERSIBLE Thrombolytics No Cath lab (w/in 90 minutes door to cath) B-Blockers DONT give IF SBP 160 or less