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ER Chest pain
| Question | Answer |
|---|---|
| Chest pain labs | CBC, CMP, Mag, LFTs, Coags, Cardiac markers, BNP, D-dimer, Urine drug screen, hCG (female) |
| The big differentials of chest pain | ACS, PE, tension pneumo, ruptured esophagus, aortic dissection |
| Chest pain history | Where? Character? How bad? Radiates? Exertional? When? Relief? Associated symptoms? |
| Chest pain risk factors | Prior? HTN, DM, Hyperlipid, Lung dis? Smoke? Recent drugs? Recent illness, injury, surgery? Family MI death < 55? |
| Admit for chest pain | Ill appearing, known heart dis, elderly w/ comorbids, unsure |
| D/C with close follow up for chest pain | Young, healthy, no comorbids |
| The smaller differentials of chest pain | Acute pericarditis, pneumonia, MVP, chest wall pain, GERD, esophageal spasm, PUD, panic d/o |
| Few seconds duration | Less concerning |
| Several minutes to an hour; relieved by rest or nitro | Concerning |
| Supplies some anterior wall and a large portion of the lateral wall | Left circumflex |
| Supplies the anterior and septum | Left anterior descending |
| Supplies the right side of the heart, and the inferior aspect of the left ventricle through the posterior descending artery | Right coronary artery |
| Pathology of ACS | Coronary artery spasm, disruption of atherosclerotic plaque, platelet aggregation, thrombus formation |
| Ischemia occurs at relatively fixed and predictable points of activity and changes slowly over time | Stable angina |
| Ischemia is relatively unpredictable (ie, at rest) and changes occur rapidly; reversible | Unstable angina |
| Irreversible necrosis | Infarction |
| Usually lasts less than 10 minutes and usually resoves with rest or NTG | Angina |
| Lasts longer than 20 minutes and little to no response to rest or NTG | MI |
| Atypical presentations occur how often | 30% - Women, elderly, diabetics |
| Chest pain with recent angioplasty or stent | Assume an abrupt vessel occlusion until ruled out |
| ST segment depression | Subendocardial ischemia |
| ST segment elevation | Acute transmural injury |
| Q waves | Myocardium in the peunumbra has died |
| Not required if you make the diagnosis on the initial EKG | Serum cardiac markers |
| What is the difference between unstable angina and NSTEMI? | Elevated serum cardiac markers (NSTEMI) |
| Rises in 4-8 hours, peaks at 12-24 hours, returns to baseline in 2-3 days; a rise 5 times above baseline is diagnostic | CK-MB |
| Rises in 6 hours, peaks in 12 hours, returns to baseline in 7-10 days; a rise is diagnostic for AMI | Troponin I and T |
| Potentially protective dysrhythmias in MI | Bradydysrhythmias |
| Dysrhythmias with poor prognosis late in MI | Tachydysrhythmias |
| Results from 40% or more of left ventricular myocardial involvement; will require careful fluid resuscitation and inotropic medications | Cardiogenic shock |
| Most common cause of AMI-related in-hospital deaths | Cardiogenic shock |
| Risk factors for cardiogenic shock | Elderly, female, previous MI, CHF, diabetes |
| Doses larger than 160mg cause immediate, nearly complete inhibition of thromboxane A2; withhold only for true allergy or active PUD | Aspirin |
| Non-aspirin antiplatelet agent associated with a higher risk of bleeding | Clopidogrel |
| Rapid reversal of platelet inhibition after cessation of infusion; offers an advantage during Percutaneous Coronary Intervention (PCI) when bleeding complications occur | Glycoprotein IIb/IIIa Inhibitors |
| Decreases ventricular filling pressures and afterload; decreases cardiac work and myocardial O2 demand; contraindicated with inferior wall MI | Nitrates |
| Nitrates used IV for first 24-48 hrs in AMI and titrated to what? | B/P NOT pain relief |
| Nitrates used IV in UA/NSTEMI if patient does not respond to what? | Sublingual nitroglycerin |
| Decreases anxiety, pain, B/P; start at 2-5mg and titrate | Morphine |
| Diminish myocardial O2 demand by decreasing the heart rate, systemic arterial pressure, and myocardial contractility; given to all ACS patients unless contraindicated | Beta-Blockers (Lopressor) |
| Relative contraindications to beta-blockers | Heart rate less than 60, SBP less than 100 |
| Non-cardioselective beta-blockers can block beta-2 subunit receptors resulting in vasoconstriction, bronchospasm, and hypoglycemia; cautious use in: | Asthma, IDDM, severe COPD |
| Specific anti-thrombin agent with unpredictable anticoagulant response due to the mixture of varying molecular weights; indicated for AMI | Unfractionated heparin |
| Specific anti-thrombin agent with greater bioavailability that achieves a more reliable anticoagulant effect; indicated for UA/NSTEMI | Low molecular weight heparin |
| Treatment time is within 6-12 hours of symptom onset and there is at least 1mm of S-T elevation in at least 2 contiguous leads; PCI not available; pain unrelieved with medications | Fibrinolytics indicated |
Created by:
codylarson
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