Chest Pain

(Non - Trauma)
Oleh : M. Samsul Arifin 0810710072 Nur Hidayati Azar 0810710088 Peppy Tria 0810710092 Tita Luthfia S 0810710107 Anantika Putri 0810713004 Arrasyid Indra 0710713025 Pembimbing : dr. Munsifah Z., SpEM

FK UNIV. BRAWIJAYA/RSU DR. SAIFUL ANWAR MALANG 2013

Introduction
Chest pain many symptoms overlap Goal in ED is to r/o life threatening causes of chest pain Need appropriate history, physical exam, and ancillary tests

LIFE-THREATENING CAUSES
Acute myocardial infarction Unstable angina

Aortic dissection
Pulmonary embolism Tension pneumothorax Oesophageal rupture

NON LIFE-THREATENING CAUSES

Cardiac Stable angina Prinzmetal angina Pericarditis/myocarditis Simple pneumothorax Pneumonia with pleurisy Reflux oesophagitis Oesophageal spasm Gastritis/PUD Biliary disease Subphrenic abscess/inflammation

Respiratory Gastrointestinal Referred pain

Chest Pain - History

Time & character of onset Quality Location Radiation Associated Symptoms Aggravating symptoms Alleviating symptoms Prior episodes Severity Review risk factors

Time & Character of Onset

Abrupt onset with greatest intensity at start : Aortic dissection, PTX, Occasionally PE will present in this manner Chest pain lasting seconds or constant over weeks is not likely to be due to ischemia

Quality
Pleuritic Pain: PE, Pleurisy, Pneumonia, Pericarditis, PTX Esophageal: Burning MI: squeezing, tightness, pressure, heavy weight on chest, can also be burning Sharp, tearing, ripping pain: Aortic Dissection

Location
If very localized, consider chest wall pain or pain of pleural origin

Associated Symptoms
Fevers, chills, URI symptoms, productive cough : Pneumonia Nausea, vomiting, diaphoresis, shortness of breath: MI Shortness of breath: PE, PTX, MI, Pneumonia, COPD/Asthma Asymmetric leg swelling: DVT PE With new onset neurologic findings or limb ischemia: consider dissection Pain with swallowing, acid taste in mouth: Esophageal disease

Aggravating Symptoms
Activity: Consider ischemic heart disease Food: Consider esophageal disease Position: If worse with laying back, consider pericarditis. Swallowing: Esophageal disease Movement: Chest wall pain Respiration: PE, PTX, Pneumonia, pleurisy Palpation: Chest Wall Pain

Alleviating Symptoms
Rest/ Cessation of Activity: Ischemic Sitting up: Pericarditis Antacids: Usually GI system

Prior Episodes
Have they had this kind of pain before Does this feel like prior cardiac pain, esophageal pain, etc What diagnostic work-up have they had so far? Last ECG, echo, last stress test, last cath, etc

Severity
Severity of chest pain

Risk Factor
Hypertension, DM, high cholesterol, tobacco, family history Long plane trips, car rides, recent surgery or immobility, hypercoagulable state: PE Uncontrolled HTN/ Marfans: Dissection Rheumatic Diseases: Pleurisy Smoking: COPD, Ischemia

Chest Pain Physical Examination

Review vital signs * Fever: Pericarditis, Pneumonia * Check BP in both arms: Dissection * Decreased sats: More commonly in pneumonia, PE, COPD * Unexplained sinus tachy: consider PE Neck * Look for tracheal deviation: PTX * Look for JVD: Tension PTX, Tamponade, (CHF) * Look for accessory muscle use: Respiratory Distress (COPD/ASTHMA)

Chest Pain Physical Examination

Chest wall exam * Look for lesions: Herpes Zoster * Palpate for localized tenderness: Likely musculoskeletal cause Lung exam * Decreased breath sounds/hyperresonance: PTX * Look for Rhonchi: Pneumonia * Listen for wheezing/prolonged expiration: COPD

Chest Pain Physical Examination

Cardiovascular Exam * Assess heart rate * Listen for murmurs, S3/S4 * Pericardial friction rub: pericarditis * Muffled heart sounds: Tamponade * Assess distal pulses

Abdominal Exam * Assess RUQ and epigastrium

NEURO EXAM * Chest pain +neurologic findings: consider dissection

Chest Pain Ancillary Tests

LABS CBC, PT/PTT, D dimer (PE), Blood cultures (pneumonia), Sputum cultures (pneumonia), Peak flow (Asthma), ABG, Cardiac Enzymes (MI), ESR (pericarditis) - Rib fractures - Hamptons Hump/Westermarks sign: PE - Infiltrates: Pneumonia - Widened mediastinum: Aortic dissection - Pneumothorax - Cardiac size: enlarged silhouette without CHF: pericardial effusion

CXR

ECG
CT Scan

MI
CT Scan Thorax if suspect PE or Aortic Dissection

Management Non Traumatic Chest Pain

Ensure vital sign are stable. If unstable, patient in distress and diaphoretic, bring patient to resuscitation area immediately Put patient on oxygen supplementation, pulse oximetry, continuous ECG monitoring, blood pressure monitoring Set up IV line and take blood test Give pain relief depending on provisional diagnosis

ACUTE MYOCARDIAL INFARCTION (AMI)

Definisi Sering disebut serangan jantung, merupakan akibat dari gangguan aliran darah ke bagian jantung, menyebabkan kematian sel jantung mati. Tanda dan Gejala Nyeri dada tiba-tiba (menyebar ke lengan kiri atau leher sebelah kiri), sesak nafas, nausea, vomiting, palpitasi, berkeringat, dan cemas.

Management AMI
O2

Aspirin 300320 mg

CPG 300 mg

S/L GTN 1 tab stat, repeat ECG after 5 minutes (to exclude ECG changes dt coronary spasm)

Consider thrombolytic therapy

Consider myocardial salvage therapy

IV GTN 20-200 microgram/min , increase by 510 microgram/min at 5-10 min intervals (if necessary)

Morphine iv 2-5 mg slow bolus (if necessary)

Indikasi Terapi Thrombolytic

Typical chest pain of AMI ST elevation of at least 1 mm in at least 2 inferior ECG leads or elevation of at least 2 mm in at least 2 contiguous anterior leads < 12 h from chest pain onset < 75 y.o of age

UNSTABLE ANGINA PECTORIS

Rapid accumulation of platelets at the rupture site and a sudden increase in obstruction to blood flow in the coronary artery

Unstable angina results from the sudden rupture of a plaque

Accumulation of platelets and obstruction to blood flow can result in a heart attack

Risk of heart attack remains even if the unstable angina symptoms lessen or disappear

Tanda dan Gejala UAP

Bisa berlangsung selama 5-20 menit. Gejala yang dirasakan : Nyeri atau tertekan Rasa berat dan tidak nyaman pada dada, leher, kerongkongan, bahu dan lengan Rasa terbakar atau indigestion Sesak Unstable angina terjadi tanpa didahului tanda awal dan terjadi saat istirahat sehingga sering mengakibatkan ansietas. Gejala lain yang bisa terjadi : Mual Nyeri kepala Keringat berlebihan

Management UAP
Nitrates - Dilatasi pembuluh darah - Mengurangi resistensi pembuluh darah mengurangi kerja jantung (workload) Beta-blockers - Memperlambat denyut jantung dan mengurangi tekanan kontraksi otot jantung Calcium channel blockers - Dilatasi pembuluh darah dan mengurangi tekanan darah

PULMONARY EMBOLISM (PE)

PE is a blockage of the main artery of the lung or one of its branches by a substance that has travelled from elsewhere in the body through the bloodstream (embolism) Origin >> DVT Virchows Triad (Endothelial Injury, Stasis, Hypercoagulability)

Clinical Symptoms of PE
Clinical symptoms suggestive of PE: Dyspnea Chest pain (Pleuritic/non pleuritic) Cough Orthopnea Calf and/or thigh pain or swelling Wheezing Common signs: Tachypnea Tachycardia Rales Decreased breath sounds Jugular venous distension Accentuated pulmonic component of second heart sound

Symptoms/ signs of lower extremity DVT include : edema, erythema, tenderness or a palpable cord.

PE Management
Initiate Heparin - Unfractionated Heparin: 80 Units/Kg bolus IV, then 18units/kg/hr - Fractionated Heparin (Lovenox): 1mg/kg SubQ BID - If high pre-test probability for PE, initiate empiric heparin while waiting for imaging - Make sure no intraparenchymal brain hemorrhage or GI hemorrhage prior to initiating heparin. Consider Fibrinolytic Therapy: - Especially if PE + hypotension

PE Management
Surgery and Other Prosedure Consider Clot removal. For a very large clot in lung and in shock, doctor may thread a thin flexible tube (catheter) through blood vessels and suction out the clot. Vein filter. Filter insertion is typically reserved for people who can't take anticoagulant drugs or when anticoagulant drugs don't work well enough Surgery. IThis happens infrequently, and the goal is to remove as many blood clots as possible, especially if there's a large clot in main (central) pulmonary artery.

AORTIC DISSECTION
Aortic dissection is an acute event where blood enters the aortic wall through a tear of the intima followed by extravasation of blood into the media. Currently believed the process begins with an intramural hematoma

Etiology
Degenerative Hypertension Pregnancy Skeletal (scoliosis) Connective tissue (Marfans) Mycotic aneurysm Takayasu (giant cell) arteritis Aortic laceration/coarctation

Aortic Dissection
Stanford Classification Type A -involves ascending aorta Type B involves descending aorta DeBakey Classification Type I ascending, arch & descending aorta Type II ascending only Type III descending only

Aortic Dissection
Clinical Features

>85% abrupt, severe pain in chest or b/w scapula

50% ripping or tearing

Pain in anterior chest ascending aorta (70%)

Back pain (less common) descending aorta (63%)

If dissection into carotid classic neuro symptoms

Aortic Dissection
Physical Exam Usually normal heart and lung exam May have aortic insufficiency <20% with decreased radial, femoral or carotid pulse Tachycardia Hyper/Hypotension

Aortic Dissection
Vasodilator Treat hypertension
Esmolol 500g/kg IV bolus over 1 minute then 50150 g/kg minute Metoprolol 5mg q2min x3 IV then 25mg/hr Propranolol 20mg IV then 40mg, 8mg q10min to 300mg total Calcium channel blocker if -blocker contraindicated

Surgery

-blocker

Nitroprusside 0.3 g/kg/min IV

OR for ascending aortic dissection

Descending aortic dissection worse surgical risks controversial for repair

TENSION PNEUMOTHORAX
Trachea deviates to contralateral side Mediastinum shifts to contralateral side Decreased breath sounds and hyperresonance on affected side JVD Treatment: Emergent needle decompression followed by chest tube insertion

NEEDLE DECOMPRESSION

Insert large bore needle (14 or 16 Gauge) with catheter in the 2nd intercostal space mid-clavicular line. Remove needle and leave catheter in place. Should hear air.

Nyeri dada pleuritik

Lokasinya posterior atau lateral. Sifatnya tajam dan seperti ditusuk. Bertambah nyeri bila batuk atau bernafas dalam dan berkurang bila menahan nafas atau sisi dada yang sakit digerakan. Nyeri berasal dari dinding dada, otot, iga, pleura perietalis, saluran nafas besar, diafragma, mediastinum dan saraf interkostalis.

Nyeri dada Non- pleuritik

Lokasinya sentral, menetap atau dapat menyebar ke tempat lain. Sering disebabkan oleh kelainan di luar paru.

Nyeri Dada Non Pleuritik

Kardial

Pulmonal

Perikardial

Fungsional

Aorta

Muskulo skleletal

Muskulo

skeletal

Trauma lokal atau radang dari rongga dada otot, tulang kartilago sering menyebabkan nyeri dada setempat. Nyeri biasanya timbul setelah aktivitas fisik.

Fungsional

Kecemasan dapat menyebabkan nyeri substernal atau prekordinal, rasa tidak enak di dada, palpilasi, dispnea, using dan rasa takut mati.

Pulmonal

Obstruksi saluran nafas atas seperti pada penderita infeksi laring kronis dapat menyebakan nyeri dada, terutama terjadi pada waktu menelan. Pada emboli paru akut nyeri dada menyerupai infark miokard akut dan substernal. Nyeri dada merupakan keluhan utama pada kanker paru yang menyebar ke pleura, organ medianal atau dinding dada.

Kardial

Angina stabil (Angina klasik, Angina of Effort), Angina tak stabil (Angina preinfark, Insufisiensi koroner akut) , Infark miokard

Perikardial

Saraf sensoris untuk nyeri terdapat pada perikardium parietalis diatas diafragma. Nyeri perikardila lokasinya di daerah sternal dan area preokordinal, tetapi dapat menyebar ke epigastrium, leher, bahu dan punggung Nyeri bisanya seperti ditusuk dan timbul pada aktu menarik nafas dalam, menelan, miring atau bergerak.

Aorta

Penderita hipertensi, koartasio aorta, trauma dinding dada merupakan resiko tinggi untuk pendesakan aorta. Diagnosa dicurigai bila rasa nyeri dada depan yang hebat timbul tiba- tiba atau nyeri interskapuler