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DU PA CP Emergencies

Duke PA Chest Pain Emergencies

What are the possible etiologies of chest pain Cardiac or vascular, pulmonary, GI, musculoskeletal, psychogenic
What is the assumption when it comes to chest pain Always assume the worst until proven otherwise
Pleuritic chest pain is worse with __ Deep inspiration
S&S of pulmonary embolus Dyspnea, pleuritic and non-pleuritic chest pain, anxiety, cough and syncope
S&S of pneumothorax Pleuritic pain, tracheal deviation, hyper resonance with decreased breath sounds unilaterally
S&S of pneumonia Pleuritic pain with associated SOB, cough, fever, sputum production, rales and dullness
S&S of asthma/COPD Dyspnea, chest tightness, wheezing, and cough
S&S of pulmonary edema Severe respiratory distress, frothy pink or white sputum, rales, S3/S4, PND, orthopnea, edema
Inflammation of pleurae, usually caused by infection or connective tissue/inflammatory disease, friction rub with low grade fever pleurisy
S&S of pulmonary hypertension Pleuritic chest pain, loud P2, right ventricular lift
S&S for GERD/heartburn Chest pain may be squeezing or pressure like, diaphoresis, radiation, N/V, post-prandial, postural changes, spasm, may be relieved with antacids/NTG
S&S of esophageal perforation Acute, severe, unrelenting and diffuse pain in chest, neck or abdomen. May radiate to back or shoulder and swallowing may exacerbate pain
S&S of Mallory-Weiss tear Hematemesis with or without prior vomiting episode
S&S of PUD Burning epigastric pain, post-prandial sx, relieved with food, may present as N/V, wt loss, anorexia and bleeding
S&S of cholecystistis Epigastric/RUQ visceral pain + fever/chills, N/V, anorexia, may radiate to back or scapular region
S&S of pancreatitis Midepigastric, piercing pain, constant, radiates to back ,associated with N/V, abdominal distention and exacerbation in supine position, low grade fever, tachy and hypo
S&S of musculoskeletal cp Sharp pain, worse with movement/palpation, true MS usually respondes to NSAIDS
S&S of anxiety/panic disorder cp Fleeting chest pain, variable onset/duration, often reproducible on palpation (but not with exertion)
Time goal of obtaining an ECG 10 minutes
What labs do you need to get for chest pain wu Cardiac biomarkers, CMB, CBC, D-dimer, PT/PTT
What types of patients are put in the chest pain observation unit Those with low probability for MI without ongoing chest pain or ischemic ECG changes
How do you r/o MI serial ECG/s and cardiac biomarkers (CK/MB, troponin levels)
CK-MB peaks in __ hours 24
CK-MB is detected in __ hours 3-12
Ck-MB lasts for __ hours after event 48-72
Deep, pressure like pain in substernal region, may radiate, SOB, transient (2-30 min), precipitated by physical exertion or emotional stress, responsive to rest or NTG Stable Angina Pectoris
Stable angina pectoris is strongly associated with what conduction abnormality LBBB
What may show up on an ECG during angina ST segment depression/possibly elevation, T wave inversion; btw episodes: 1/3 of pts have normal resting ECG
Treatment for stable angina pectoris Risk factor modification, 81-325 ASA daily, beta blocker, ACEI, Nitrates, statins/lipid agents, consider revascularization
Treatment for patient with unstable angina Admit/monitor/bed rest, MOAN (Morphine, O2, ASA, NTG)
Over 50% of deaths from acute STEMI occur within __ of event from __ 1 hour, v-fib
How soon do T waves peak with an acute STEMI 0-6 hours
How soon may you see ST segment elevations with an acute STEMI 0-18 hours
How long does it take for an ECG to Q out following an acute STEMI About 18 hours
What ECG finding is indicative of myocardial ischemia ST elevation at the J point in 2 or more contiguous leads
What ECG findings are suggestive of myocardial ischemia that may progress to MI ST depression, T wave abnormalities
The initial ECG is negative or non-diagnostic in up to __% of patients having an acute myocardial infarction 40
In an inferior MI ST changes will be seen in what leads II, III, and aVF
In an anterior MI ST changes will be seen in what leads V2-V5 or V1-V4
In a lateral MI ST changes will be seen in what leads I, aVL, V5-V6
In an inferolateral MI ST changes will be seen in what leads II, III, aVF, I, aVL
In an anterolateral MI ST changes will be seen in what leads V4-V6, I, aVL
In a right ventricle MI, ST changes will be seen in what leads R sided and V1R to V6R
ST elevation typically persists __ after onset of chest pain in a STEMI if no reperfusion therapy is done 6-18 hours
What is the goal door to balloon time <90 min
What are the absolute contraindications for lytics with acute STEMI Prior intra-cranial hemorrhage, cerebral AVM, malignant neoplasm, active bleeding, suspected aortic dissection, ischemic CVA in past 3 months or closed head trauma, severe uncontrollable HTN
Unexpected non-traumatic death in clinically well or stable patients who die within 1 hour after onset of symptoms Sudden cardiac death
What is the usual causative rhythm associated with sudden cardiac death V-tach except in the setting of acute ischemia or infarction (then VF arrest)
When do most sudden cardiac deaths occur In the early morning hours
List some conditions that can cause the following; chest pain, hypotension/shock, JVD MI, arrhythmia, tamponade, massive PE, tension pneumo
List some conditions that can cause chest pain and hypovolemia MI, Aortic dissection, leaking AAA
Name the valvular abnormality; mid-systolic click, inverted T waves on inferior leads Mitral valve prolapse
Name the valvular abnormality; systolic ejection murmur transmitted to carotids, LVH on ECG Aortic stenosis
Name the valvular abnormality; diastolic murmur transmitted to carotid arteries, wide arterial pulse pressure, ECG may show LVH Aortic regurgitation
What are some factors that increase the risk of an aortic dissection Male, 60-70 yo, pregnancy, connective tissue disorders (Marfan’s, Ehlers Danlos), hypertension, bicuspid aortic valve, coarctation of the aorta
Intimal tear in aorta that creates a false lumen between media and adventitia Aortic dissection
Where do >95% of aortic dissections occur Ascending aorta just distal to aortic valve or just distal to the left subclavian (fixed points)
What is a Stanford A aortic dissection Any involvement of ascending aorta
What is a Stanford B arotic dissection Not involving ascending aorta
What is a DeBakey I aortic dissection Ascending aorta extending to distal (entire length)
What is a DeBakey II aortic dissection Ascending aorta only (before left subclavian)
What is a DeBakey III aortic dissection Descending aorta only (after left subclavian)
A Stanford A aortic dissection is the same as which DeBakey classifications I and II
A Stanford B aortic dissection is the same as which DeBakey classification III
Symptoms of aortic dissection Sudden onset retrosternal and back pain, may see infarct patterns on ECG, neuro deficits/CVA, limb ischemia, syncope, shock, hypertensive, pulse discrepancies
What may a chest x-ray look like in a patient with an aortic dissection Widened mediastinum, possibley left sided pleural effusion
When may an MRI be useful in an aortic dissection For serial follow up
Treatment for an aortic dissection Achieve relative hypotension and bradycardia (beta blocker first then nitroprusside to maintain SBP of 100-120 mmHg), contact cardiothoracic surgeon
What Stanford class of aortic dissection needs surgical repair A
What Stanford class of aortic dissection can be treated medically B (exceptions are rupture, limb or visceral ischemia, ongoing pain, saccular morphology, uncontrolled HTN, Marfan’s or AI
Clinical findings of an abdominal aortic aneurysm Majority are asymptomatic, prominent aortic pulsation, pain (epigastric fullness or lower back and hypogastric region), gnawing, hours/days not positional
What change in symptoms indicates rupture of AAA Severe back or abdominal pain and hypotension
What is the next step if diagnosis of AAA is clear on clinical grounds Emergent vascular surgery consult
What is the next step if a patient with an AAA is hemodynamically stable Bedside abdominal ultrasound (100% sensitive, unless rupture has already occurred)
Mass effect associated with thoracic AA SVC syndrome, tracheal deviation, cough, hemoptysis, dysphagia, hoarseness
Symptoms of acute pericarditis Pleuritic, sharp, stabbing chest pain that radiates to shoulders, back, neck that is worse on deep inspiration or movement, worse supine and relieved by sitting up and leaning forward. Low grade fever, dyspnea, friction rub LLSB
ECG changes in acute pericarditis Diffuse upsloping ST segment elevations
Labs to get for evaluation of acute pericarditis CBC with diff, BUN/creatinine, serologies (strep, ANA, viral), thyroid
Treatment of stable patient with acute pericarditis Out patient with NSAIDS for 1-3 weeks
When should a patient with acute pericarditis be admitted Myocarditis, uremic pericarditis, enlarged cardiac silhouette on CXR, or hemodynamic compromise
The most common patient population that gets tamponade has some type of __ Malignancy
Occurs when pressure in the pericardial sac exceeds normal RV filling pressure, resulting in restricted filling and decreased cardiac output Cardiac tamponade
What is beat to beat variability in the amplitude of the P and R waves unrelated to inspiratory cycle and is diagnostic of cardiac tamponade Electrical alternans
S and S of cardiac tamponade Shortness of breath, weakness (more likely than chest pain and tachycardia), JVD, pulsus paradoxus, electrical alternans, large cardiac silhouette on CXR
What is an exaggeration in the normal variation in the pulse during the inspiratory phase of respiration, in which the pulse becomes weaker as one inhales and stronger as one exhales Pulsus paradoxus
What is Beck’s triad Hypotension, elevated systemic venous pressures, small quiet heart
The presence of Beck’s triad is indicative of what condition Cardiac tamponade
Treatment of cardiac tamponade Volume resuscitation, pericardiocentesis, admit and consider pericardial window
Severe elevation of BP, no evidence of progressive TOD, absence of raised intracranial pressure Hypertensive urgency
Hypertensive urgency benefits from BP lowering in __ A few hours
Short term treatment for hypertensive urgency Labetalol, clonidine or captopril, outpatient follow up within 72 hours
Acute, severe elevation in BP, evidence of rapidly progressive TOD (MI, pulmonary edema, stroke, renal failure) Hypertensive emergency
Hypertensive emergency requires __ Immediate, gradual reduction of BP( not to the normal range)
In a patient with hypertensive emergency rapid correction of BP to normal levels puts the patient at risk of what Worsening cerebral, renal, or cardiac ischemia
What is the goal of treatment in hypertensive emergency 10% decrease in first hour, 15% over next 3-12 hours to BP of no less than 160/110
What must be present to kick hypertensive emergency up to the level of malignant hypertension Papilledema
Do not ignore __ in patients with many low risk findings A few high risk findings
cardiac enzymes: normal in stable angina/USA; elevated in NSTEMI/STEMI
Thoracic AA: vascular sx CHF, ischemia, thromboembolism
Conditions that may precipitate tamponade: Malignancy induced pericarditis; Aortic dissection; MI with Ventricular rupture; Pacemaker perforation during implant
Created by: bwyche