Beruflich Dokumente
Kultur Dokumente
UpToDate
Typical vs. Atypical Chest Pain
Cayley 2005
Case 1
You are the orphan intern on Wearn team at 6PM. You
are called by the nurse because Ms. Z has developed
chest pain. Ms. Z is a 62 yo F with PMHx of CAD s/p
remote PCI to the LAD, COPD and right THA 3 weeks
ago who was admitted for a COPD exacerbation.
What would you do next?
Evaluation of Chest Pain
Case 1:
Ask nurse for most current set of vital signs
Ask nurse to get an EKG
Obtain the admission EKG from the paper chart
Go see the patient!
Evaluation of Chest Pain
Once at bedside, determine if patient is stable or unstable
Perform focused history and physical exam
Read and interpret the EKG. Compare EKG to old EKG if
available
If patient looks unstable or has concerning EKG findings, call
your senior resident for help
Write a clinical event note!
Evaluation of Chest Pain
focused physical exam for chest pain
Vital Signs: tachycardia, hypertension/hypotension or hypoxia
General: Sick appearing, actively having chest pain
HEENT: JVD, carotid bruits
Chest: Rales, wheezes or decreased breath sounds
CVS: New murmurs, reproducible chest pain, s3 gallop
Abd: Abdominal tenderness, pulsatile mass
Ext: Edema, peripheral pulses
Skin: Rash on chest wall
Case 1
You go see the patient. She had been feeling better after getting
duonebs, but suddenly developed chest pain that is L-sided, 8/10
and worse with breathing. This pain is not like her prior MI.
Vital signs: Afebrile, HR 120, BP 110/70, RR 28, O2 sat 89% on 2L
(was 95% on RA this morning)
Physical exam
Gen – in distress, using accessory muscles of respiration
Lungs – CTAB, no rales/wheezes
Heart – tachycardic, nl s1, loud s2, no mumurs
Abd – soft, NT/ND, active BS
Ext – b/l LEs warm and well perfused
Labs:
CBC wnl, RFP wnl, BNP = 520, D-dimer = positive, Troponin = 0.12
Case 1
Case 1
Differential
Modified Wells Criteria
Clinical symptoms of DVT (3 points)
Other diagnoses less likely than PE (1 point)
Heart Rate >100 (1.5 points)
Immobilization >/= 3 days or surgery within 4 weeks (1.5 points)
Previous DVT/PE (1.5 points)
Hemoptysis (1 point)
Malignancy (1 point)
Interpretation:
>6: high
2-6: moderate
<2: low
Next moves
DDIMER: 95% sensitive, VERY nonspecific
ABG – Elevated A-a gradient fairly sensitive, highly
nonspecific
EKG – most commonly nonspecific changes (ST/T wave
changes, etc)
V/Q scan – helpful in patients with HIGH or LOW pretest
probabilities in whom a CTPE cannot be obtained (eg CKD)
LE Ultrasound: not sensitive
CTPE
Sensitivity 83%
Specificity 96%
Moderate - high clinical probability and positive CTPE: 92-96%
chance of PE
Pearl
A CT angiogram (important for evaluating for Pulmonary
Embolism or Aortic Dissection) requires EITHER:
OR
Stabliize patient
oxygen
Fluids if hypotensive!
Anticoagulants
Preferred: LMWH or Fondaparinux
Enoxaparin 1.5mg/kg daily or 1mg/kg BID
Fondaparinux subcutaneous once daily (weight based)
Alternative: UFH (IV or SC) – select high intensity protocol
Hemodynamically unstable patients
High risk of bleeding (reversible)
GFR < 30
Can initiate warfarin on same day
IVC filter an alternative in patients with mod-high bleeding risk
Search “heparin infusion orders”
Pearl: If you have a moderate
or high suspicion of PE, you
can start anticoagulation while
awaiting full diagnostic workup
PE with hypotension
Thrombolysis
Administer over short infusion time
Catheter based thrombectomy
For failure of thrombolysis or likelihood of shock/death before
thrombolysis can take effect (hours)
Surgical thrombectomy
Failure of above therapies
Case 2
“Stabilize” plaque
Dual antiplatelet therapy
Plavix load 600mg followed by daily 75mg
ASA 324mg chewable, then 81 daily
Anticoagulant
UF Heparin at low intensity protocol
Statin
Atorvastatin 80mg
Optimize Myocardial O2 supply/demand
Control HR -> Short acting metoprolol, can titrate quickly to HR <60 if
BP allows. Give 5mg IV, can repeat at 5-15min intervals. Be wary of
patients with heart failure!
Supplemental O2 if hypoxemic
SL nitroglycerin (0.4mg), repeat every 4-5 minutes
Morphine if still having active chest pain
Case 2 continued
You are now the nightfloat intern, and the patient is signed
out to you at 10PM. At midnight, you are called for continued
chest pain. Improved from admission but still 5/10 severity.
Next steps
Vitals
Repeat EKG
Repeat SL nitro
Assess patient in person
Call your senior!
=
Urgent call to cardiology for consideration of
immediate catheterization
Trivia
What typical ACS med should you
NOT give this patient?
Pearl: Nitroglycerin contraindicated
in inferior MI
Images:
reference.medscape.com
rwjms1.umdnj.eduen.wikipedia.org
en.wikipedia.org
Thoracic aortic dissection
Risk Factors
Hypertension
Atherosclerosis
Preexisting aneurysm (known history in 13% of patients)
Inflammatory conditions affecting aorta (Takayasu, Giant Cell
Arteritis, RA, syphilis)
Collagen disorders (Marfan, Ehlers-Danlos)
Bicuspid aortic valve
Aortic coarctation
Turner syndrome
History of CABG, AVR, Cardiac Cath
High intensity weight lifting
Cocaine use
Trauma
Thoracic aortic dissection
Management
Type A Type B
Goyle 2002
Case 4 - Pericarditis
Diagnostic criteria
UpToDate 2012
Case 4 – Pericarditis
Per 2003 ACC guidelines, all patients diagnosed with
pericarditis should receive echocardiogram
High risk features:
Fever (>38ºC [100.4ºF]) and leukocytosis
Evidence suggesting cardiac tamponade
A large pericardial effusion (ie, an echo-free space of more than
20 mm)
Immunosuppressed state
A history of therapy with vitamin K antagonists (eg warfarin)
Acute trauma
Failure to respond within seven days to NSAID therapy
Elevated cardiac troponin, which suggests myopericarditis
Case 4 - Pericarditis
Treatment
UpToDate 2012
Case 5
This is a 45 yro M with PMHx of rheumatoid arthritis who
presented with progressive sob. He was found to have a R-
sided pleural effusion and underwent an US guided
thoracentesis with removal of 1.5 liters of pleural fluid. Two
hours after his procedure, he develops new onset R-sided
chest pain
Case 5
Case 5 - Pneumothorax
Management of Pneumothorax
100% O2 and observation in stable patients for PTX < 3 cm in
size
Needle aspiration in stable patients for PTX >3 cm
Chest tube placement if PTX >3 cm and if needle aspiration fails
Chest tube placement in unstable patients
Pearl