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Chest PainChest PainWilliam Beaumont HospitalWilliam Beaumont Hospital
Department of Emergency Department of Emergency MedicineMedicine
The things that kill…The things that kill…
Acute MIAcute MI PEPE Pneumothorax (ptx)Pneumothorax (ptx) Aortic DissectionAortic Dissection Esophageal Rupture (Boerhaave’s)Esophageal Rupture (Boerhaave’s)
Let’s dive right Let’s dive right inin……
Chest Pain: what is it?Chest Pain: what is it?65 y/o male complains of substernal 65 y/o male complains of substernal
chest pressure and tightening that chest pressure and tightening that radiates to his left arm, shortness of radiates to his left arm, shortness of breath, diaphoresis, and nausea that breath, diaphoresis, and nausea that started while working in the yard.started while working in the yard.
Pmhx: HTN, high cholesterolPmhx: HTN, high cholesterolSoc: + tobaccoSoc: + tobaccoFHx: father died at 62 of MIFHx: father died at 62 of MI
Chest Pain: what is it?Chest Pain: what is it?
86 y/o female presents with generalized 86 y/o female presents with generalized weakness, mental status changes, weakness, mental status changes, vomiting, epigastric pain, and syncope vomiting, epigastric pain, and syncope after her last episode of vomiting.after her last episode of vomiting.
There is no other history as the NH did There is no other history as the NH did not feel it was necessary to send her not feel it was necessary to send her records.records.
Chest Pain: what is it?Chest Pain: what is it?
36 y/o obese, diabetic male presents with 36 y/o obese, diabetic male presents with weakness, fatigue. shortness of breath weakness, fatigue. shortness of breath whenever he gets off the couch, and whenever he gets off the couch, and “just not feeling right, doc.”“just not feeling right, doc.”
Pmhx: diabetes since his teens, HTN, high Pmhx: diabetes since his teens, HTN, high cholesterolcholesterol
FHx: mom – HTN, dad- “had a bad heart”FHx: mom – HTN, dad- “had a bad heart”
Acute Coronary Syndrome Acute Coronary Syndrome (ACS)(ACS)
Includes USA, NSTEMI, STEMIIncludes USA, NSTEMI, STEMI Leading cause of death among adults Leading cause of death among adults
in the US (about 1 million, 2006)in the US (about 1 million, 2006) 6 million people present to the ER per 6 million people present to the ER per
year with chest pain, 2 million of year with chest pain, 2 million of these receive the diagnosis of ACSthese receive the diagnosis of ACS
Cost of doing business: $100-120 Cost of doing business: $100-120 billionbillion
Risk factors for CADRisk factors for CAD
TypicalTypical MaleMale Older AgeOlder Age TobaccoTobacco HTNHTN DMDM High CholesterolHigh Cholesterol FHxFHx CocaineCocaine Artificial/early Artificial/early
menopausemenopause
AtypicalAtypical DMDM ElderlyElderly FemaleFemale NonwhiteNonwhite DementiaDementia No history of MINo history of MI No history of high No history of high
cholesterolcholesterol CHFCHF CVACVA
Unstable Angina (USA) Unstable Angina (USA) DefinedDefined
New onset angina occurring with New onset angina occurring with minimal exertion or at rest, worsening of minimal exertion or at rest, worsening of previous angina, increased frequency or previous angina, increased frequency or duration of attack, and resistance to duration of attack, and resistance to previous treatmentprevious treatment
USA should be treated aggressively as it USA should be treated aggressively as it may be the precursor to AMI -> Admit to may be the precursor to AMI -> Admit to step down unit, IV NTG (if CP continues), step down unit, IV NTG (if CP continues), IV Heparin, aspirinIV Heparin, aspirin
ECG: normal/unchanged, nonspecific ST ECG: normal/unchanged, nonspecific ST segment changes, or T wave inversionssegment changes, or T wave inversions
Acute Myocardial Infarction Acute Myocardial Infarction (AMI)(AMI)
DefinitionDefinition Rise and fall of cardiac biomarkers with the Rise and fall of cardiac biomarkers with the
followingfollowing Ischemic symptoms (critical vessel stenosis with Ischemic symptoms (critical vessel stenosis with
increased myocardial work load or plaque increased myocardial work load or plaque rupture)rupture)
Development of q waves on ecgDevelopment of q waves on ecg ST segment elevation or depression (STEMI and ST segment elevation or depression (STEMI and
NSTEMI)NSTEMI) Coronary artery intervention (lytics or cath lab)Coronary artery intervention (lytics or cath lab)
Pathologic findings of acute MIPathologic findings of acute MI
NSTEMI DefinitionNSTEMI Definition
Positive cardiac enzymes in the Positive cardiac enzymes in the appropriate clinical scenario without appropriate clinical scenario without ST elevation on the ecgST elevation on the ecg
Ecg – normal, t wave inversions, ST Ecg – normal, t wave inversions, ST segment depressionssegment depressions
ECG Findings of ACSECG Findings of ACS Hyperacute T wavesHyperacute T waves ST segment elevation of 1 mmST segment elevation of 1 mm ST segment depression – NSTEMI vs ST segment depression – NSTEMI vs
reciprocal changesreciprocal changes T wave inversions – initial presentation T wave inversions – initial presentation
or evolving infarctor evolving infarct Q waves – may emerge in the initial Q waves – may emerge in the initial
hour, but usually develop at 8-12 hour, but usually develop at 8-12 hourshours
Normal ECGNormal ECG
Injury Patterns on the ECGInjury Patterns on the ECGAnterior wall MI: Anterior wall MI: ST segment elevation V1-ST segment elevation V1-
V4V4
Vessel: LADVessel: LAD
Injury Patterns on the ECGInjury Patterns on the ECG
Anterior wall MI: Anterior wall MI: ST segment elevation V1-ST segment elevation V1-V4V4
Injury Patterns on the ECGInjury Patterns on the ECGLateral Wall MI: I, aVL, V5, V6Lateral Wall MI: I, aVL, V5, V6
Vessel: variable perfusion of LAD, Vessel: variable perfusion of LAD, RCA, LCxRCA, LCx
Injury Patterns on the ECGInjury Patterns on the ECGAnterolateral with reciprocal changesAnterolateral with reciprocal changes
Vessels: LAD and 1Vessels: LAD and 1stst diagonal branch diagonal branch
Injury Patterns on the ECGInjury Patterns on the ECGInferior wall MI: II, III, aVFInferior wall MI: II, III, aVF
Vessel: 90% RCA, 10% LCxVessel: 90% RCA, 10% LCx
Injury Patterns on the ECGInjury Patterns on the ECGPosterior Wall MI: Posterior Wall MI: V1-V3 depression, tall V1-V3 depression, tall
upright T, tall wide R wave, R/S ratio upright T, tall wide R wave, R/S ratio greater than 1greater than 1
Vessel: RCA, PDA, LCxVessel: RCA, PDA, LCx
Injury Patterns on the ECGInjury Patterns on the ECGInferior Wall MI with Posterior Wall MI: Inferior Wall MI with Posterior Wall MI:
V1-V3 depression, tall upright T, tall wide V1-V3 depression, tall upright T, tall wide R wave, R/S ratio greater than 1R wave, R/S ratio greater than 1
Vessel: RCA, PDA, LCxVessel: RCA, PDA, LCx
Injury PatternsInjury PatternsWhat is this?What is this?
Injury PatternsInjury PatternsPericarditis: Pericarditis: diffuse ST elevation except diffuse ST elevation except
aVRaVR
Moving on…Moving on…What do you want to order What do you want to order in addition to an ecg for a in addition to an ecg for a patient presenting with patient presenting with chest pain, suspected ACS?chest pain, suspected ACS?
Initial EvaluationInitial Evaluation IV, O2, monitorIV, O2, monitor Focused H&PFocused H&P CBCCBC Chem 7Chem 7 CK-MB, troponin, myoglobinCK-MB, troponin, myoglobin CXRCXR PT/PTTPT/PTT Possible d-dimerPossible d-dimer ? Repeat ecg? Repeat ecg
Treatment in the EC: Treatment in the EC: STEMI/AMISTEMI/AMI
Activate the AMI page and cath labActivate the AMI page and cath lab ASA 325mg po – proven to save livesASA 325mg po – proven to save lives NTG SL and gtt- reduces NTG SL and gtt- reduces
preload>afterload, dilates coronary preload>afterload, dilates coronary arteriesarteries
Heparin 60 U/kg bolus then 16 U/kg/hourHeparin 60 U/kg bolus then 16 U/kg/hour B Blocker – decrease catecholamine B Blocker – decrease catecholamine
driven tachycardia and contractility, driven tachycardia and contractility, therefore decreasing myocardial oxygen therefore decreasing myocardial oxygen demanddemand
Treatment in the EC: Treatment in the EC: STEMI/AMISTEMI/AMI
Morphine – for persistent pain or anxiety to Morphine – for persistent pain or anxiety to reduce O2 need, weak sympathetic reduce O2 need, weak sympathetic blocker, preload reducer through venous blocker, preload reducer through venous dilationdilation
Glycoprotein IIb/IIIA inhibitors – started in Glycoprotein IIb/IIIA inhibitors – started in the EC or cath lab for those patients the EC or cath lab for those patients undergoing mechanical coronary undergoing mechanical coronary interventionintervention
Plavix – in consultation with the Plavix – in consultation with the cardiologist as it prohibits CABG for 5 dayscardiologist as it prohibits CABG for 5 days
Treatment in the EC: Treatment in the EC: STEMI/AMISTEMI/AMI
Reperfusion TherapyReperfusion Therapy PCI – the 90 minute rulePCI – the 90 minute rule
Most people are eligibleMost people are eligible Decreased risk of bleeding and strokeDecreased risk of bleeding and stroke Higher initial reperfusion ratesHigher initial reperfusion rates Defines coronary vasculature and allows Defines coronary vasculature and allows
for treatment vs. surgical referralfor treatment vs. surgical referral t-PA – when PCI cannot be achieved in t-PA – when PCI cannot be achieved in
90 minutes or is not available at the 90 minutes or is not available at the institutioninstitution 0-12 hours after symptom onset0-12 hours after symptom onset
NTG NTG When to think twice?When to think twice?
NTG: be cautious…NTG: be cautious…
BradycardiaBradycardia HypotensionHypotension Inferior or posterior wall MI with RV Inferior or posterior wall MI with RV
INFARCTINFARCT Decreased preload will cause sudden Decreased preload will cause sudden
hypotension and increase infarct sizehypotension and increase infarct size These patients need fluids to increase preload These patients need fluids to increase preload
and help fill the malfunctioning/weakened and help fill the malfunctioning/weakened ventricleventricle
Treatment in the EC: Treatment in the EC: USA/NSTEMIUSA/NSTEMI
Basically the same, but without the Basically the same, but without the cath lab or fibrinolyticscath lab or fibrinolytics
IV, O2, monitorIV, O2, monitor ASA, heparin, ntg, B blocker, ASA, heparin, ntg, B blocker,
morphinemorphine Plavix and G IIb/IIIa inhibitors Plavix and G IIb/IIIa inhibitors
potentially after discussion with potentially after discussion with cardiologycardiology
Admit to a monitored unitAdmit to a monitored unit
Chest Pain: low risk, but risky Chest Pain: low risk, but risky enoughenough
Patients who are low risk with risk Patients who are low risk with risk factors (silly isn’t it?), chest pain free, factors (silly isn’t it?), chest pain free, and have a normal ecg and enzymesand have a normal ecg and enzymes
Observation unit for serial cardiac Observation unit for serial cardiac enzymes and ecgenzymes and ecg
Stress test vs. CTAStress test vs. CTA Cardiology consult variableCardiology consult variable
Questions about ACS?Questions about ACS?
Chest Pain: what is it?Chest Pain: what is it?
38 y/o female presents with sudden 38 y/o female presents with sudden onset of chest pain and shortness of onset of chest pain and shortness of breath shortly after retrieving her bags breath shortly after retrieving her bags at the baggage claim from a flight at the baggage claim from a flight home from Hawaii. She states that it is home from Hawaii. She states that it is worse when she takes a deep breath. worse when she takes a deep breath. She also complains of this aching pain She also complains of this aching pain in her R leg when walking.in her R leg when walking.
Chest Pain: What is it?Chest Pain: What is it?80 y/o bedridden patient sent from the NH with 80 y/o bedridden patient sent from the NH with
mental status changes and hemoptysis. She mental status changes and hemoptysis. She is pleasant during the conversation, but has is pleasant during the conversation, but has no idea why she is here. She is actively no idea why she is here. She is actively coughing and appears to have increased coughing and appears to have increased work of breathing.work of breathing.
Vitals: HR 110 BP 90/60 RR 28 sPO2 88% RAVitals: HR 110 BP 90/60 RR 28 sPO2 88% RA
Lungs: bibasilar rales with R mid lung rhonchiLungs: bibasilar rales with R mid lung rhonchi
PMHx: positive for almost everything (she is 80)PMHx: positive for almost everything (she is 80)
Chest Pain: What is it?Chest Pain: What is it?29 y/o obese white female with history of 29 y/o obese white female with history of
fibromyalgia and chronic back pain presents fibromyalgia and chronic back pain presents with R neck and shoulder pain. She woke-up with R neck and shoulder pain. She woke-up with it this morning, it is similar but worse than with it this morning, it is similar but worse than her usual aches. It hurts to move, turn, her usual aches. It hurts to move, turn, breathe, and live. She went to work today, but breathe, and live. She went to work today, but the aching was so bad that she had to come to the aching was so bad that she had to come to the ER. Chart review shows that she was here the ER. Chart review shows that she was here 3 weeks ago for similar pain in her neck and 3 weeks ago for similar pain in her neck and lower back.lower back.
Vitals: HR 126 BP 130/90 RR 28 sPO2 90% RAVitals: HR 126 BP 130/90 RR 28 sPO2 90% RA
PE – 2006 statsPE – 2006 stats
Approximately 1 in every 500-1000 Approximately 1 in every 500-1000 EC patients has a PEEC patients has a PE
ECPs correctly diagnose about 50%ECPs correctly diagnose about 50% 10% of EC patients with PE die within 10% of EC patients with PE die within
30 days even when PE is promptly 30 days even when PE is promptly diagnosed and treateddiagnosed and treated
PEPERISK FACTORSRISK FACTORS CarcinomaCarcinoma ImmobilityImmobility Trauma or surgery Trauma or surgery
in the last 4 weeksin the last 4 weeks SmokingSmoking Estrogen/OCPEstrogen/OCP Pregnancy/PPPregnancy/PP ThrombophiliaThrombophilia Connective Tissue Connective Tissue
DzDz Prior PE or DVTPrior PE or DVT
Signs and Signs and SymptomsSymptoms
Chest PainChest Pain DyspneaDyspnea HemoptysisHemoptysis SplintingSplinting SyncopeSyncope HR > 100HR > 100 Pulse ox < 95%Pulse ox < 95% Unilateral arm or Unilateral arm or
leg swellingleg swelling
PE - DiagnosisPE - Diagnosis Basic Labs – CBC and Chem 7Basic Labs – CBC and Chem 7 ? Labs – ck-mb, troponin, PT/PTT? Labs – ck-mb, troponin, PT/PTT D dimer- low risk patients only with low D dimer- low risk patients only with low
pretest probabilitypretest probability CXR CXR
exclude other diagnosis – CHF, pna, ptxexclude other diagnosis – CHF, pna, ptx unilateral basilar atelectasis increases the unilateral basilar atelectasis increases the
probability of PEprobability of PE Hamptom’s hump – wedge shaped infarctionHamptom’s hump – wedge shaped infarction Westermark’s sign – unilateral lung oligemiaWestermark’s sign – unilateral lung oligemia
PE - CXRPE - CXR
Hampton’s HumpHampton’s Hump Westermark’s SignWestermark’s Sign
PE - DiagnosisPE - Diagnosis EcgEcg
Again to exclude other diagnosisAgain to exclude other diagnosis Most common finding is sinus tachycardiaMost common finding is sinus tachycardia T wave inversions v1-v4T wave inversions v1-v4 McGinn-White Pattern – s1q3t3McGinn-White Pattern – s1q3t3 New incomplete or complete RBBBNew incomplete or complete RBBB
Chest CT – moderate to high risk Chest CT – moderate to high risk patients or pre-test probability, patients or pre-test probability, positive d-dimerpositive d-dimer
PE - ECGPE - ECG
PE - ECGPE - ECG
PE - TreatmentPE - Treatment Heparin unfractionated 80 u/kg bolus then Heparin unfractionated 80 u/kg bolus then
18 u/kg/hour18 u/kg/hour LMWH 1 mg/kg SQ q12 hoursLMWH 1 mg/kg SQ q12 hours Coumadin – usually started on the floorCoumadin – usually started on the floor IVC filter – for pts who failed anticoagulation IVC filter – for pts who failed anticoagulation
or have contraindicationsor have contraindications Thrombolytics – consider in high risk pts Thrombolytics – consider in high risk pts
such as systolic hypotension, persistent such as systolic hypotension, persistent hypoxemia, elevated troponin or BNP (early hypoxemia, elevated troponin or BNP (early shock or shock)shock or shock)
Surgery – large clot burden, refractory Surgery – large clot burden, refractory hypotension, floating emboli in the R hearthypotension, floating emboli in the R heart
PEPEAny Questions?Any Questions?
Chest Pain: What is it?Chest Pain: What is it?
18 y/o tall, thin healthy male c/o 18 y/o tall, thin healthy male c/o sudden onset L sided CP with sudden onset L sided CP with shortness of breath. The pain started shortness of breath. The pain started while he was inhaling on a marijuana while he was inhaling on a marijuana cigarette. It hurts more to breathe.cigarette. It hurts more to breathe.
Vitals: HR 110 RR 28 BP 110/70 sPO2 Vitals: HR 110 RR 28 BP 110/70 sPO2 96%96%
Chest Pain: What is it?Chest Pain: What is it?
60 y/o male with a history of severe COPD 60 y/o male with a history of severe COPD c/o increasing shortness of today that is c/o increasing shortness of today that is not relieved with his home inhalers.not relieved with his home inhalers.
Vitals: HR 110 RR 28 BP 110/70 sPO2 90%Vitals: HR 110 RR 28 BP 110/70 sPO2 90%
Heart: distant, tachycardic and regularHeart: distant, tachycardic and regularLungs: diffuse wheezing, decreased breath Lungs: diffuse wheezing, decreased breath
sounds on the rightsounds on the right
PneumothoraxPneumothorax Primary Spontaneous – occurs in Primary Spontaneous – occurs in
people without clinically apparent lung people without clinically apparent lung diseasedisease 15/100,000 in men, 5/100,000 in women15/100,000 in men, 5/100,000 in women Associated factors = tall, smoking, Associated factors = tall, smoking,
changes in ambient atmospheric pressure, changes in ambient atmospheric pressure, genetics, MVP, Marfan’s syndromegenetics, MVP, Marfan’s syndrome
Disruption of the alveolar-pleural barrier is Disruption of the alveolar-pleural barrier is thought to occur when a bleb or bulla thought to occur when a bleb or bulla ruptures into the pleural spaceruptures into the pleural space
PneumothoraxPneumothorax Secondary Spontaneous – occur with Secondary Spontaneous – occur with
known underlying pulmonary diseaseknown underlying pulmonary disease Three times more common in menThree times more common in men Associated with any underlying Associated with any underlying
pulmonary disease including infection, pulmonary disease including infection, ILD, neoplasms, COPD, asthma, etc…ILD, neoplasms, COPD, asthma, etc…
Weakening of the alveolar-pleural barrier Weakening of the alveolar-pleural barrier occurs secondary to the underlying lung occurs secondary to the underlying lung disease either from inflammation or disease either from inflammation or development of bullaedevelopment of bullae
PneumothoraxPneumothorax
IatrogenicIatrogenic Complication of intubation or aggressive Complication of intubation or aggressive
BVM, central line placement, or any BVM, central line placement, or any endoscopic procedure involving the endoscopic procedure involving the trachea or esophagustrachea or esophagus
Consider in any stable patient with Consider in any stable patient with acute deterioration, hypoxia, or acute deterioration, hypoxia, or increased difficulty with ventilationincreased difficulty with ventilation
Tension PneumothoraxTension Pneumothorax
Positive intrapleural pressure causes Positive intrapleural pressure causes compression of the mediastinum and compression of the mediastinum and the contralateral lungthe contralateral lung
Pressure exceeding 15 to 20 mm Hg Pressure exceeding 15 to 20 mm Hg impairs venous return to the heartimpairs venous return to the heart
Leads to cardiovascular collapse if Leads to cardiovascular collapse if not treated immediately -> this is a not treated immediately -> this is a clinical diagnosis not a radiographic clinical diagnosis not a radiographic one!one!
PneumothoraxPneumothoraxClinical PresentationClinical Presentation
SymptomsSymptoms Ipsilateral sharp CPIpsilateral sharp CP DyspneaDyspnea Pleuritic painPleuritic pain CoughCough
SignsSigns Sinus tachycardiaSinus tachycardia HyperresonanceHyperresonance Decreased breath Decreased breath
soundssounds Unilateral enlargement Unilateral enlargement
of the hemithoraxof the hemithorax SplintingSplinting HypoxiaHypoxia
Pneumothorax: DiagnosisPneumothorax: Diagnosis
Clinically for tension PTXClinically for tension PTX CXRCXR
Radiolucent band devoid of lung markingsRadiolucent band devoid of lung markings Inspiratory/expiratory viewsInspiratory/expiratory views Lateral decubitus views in sick patientsLateral decubitus views in sick patients Supine CXR may have deep sulcus signSupine CXR may have deep sulcus sign
Thoracic UltrasoundThoracic Ultrasound Chest CTChest CT
PneumothoraxPneumothorax
Pneumothorax - TensionPneumothorax - Tension
Pneumothorax – Deep Sulcus Pneumothorax – Deep Sulcus SignSign
Pneumothorax: Pneumothorax: ManagementManagement
Tension – needle decompressionTension – needle decompression Tube thoracostomy –> 20-28 F for Tube thoracostomy –> 20-28 F for
air, 32F at least if fluid is presentair, 32F at least if fluid is present Observation – for PTX < 20% collapseObservation – for PTX < 20% collapse
Reabsorption RateReabsorption Rate 1-2% per day1-2% per day 4-8% if on 100% NRB4-8% if on 100% NRB
Pneumothorax – Pneumothorax – any questions?any questions?
Chest Pain: what is it?Chest Pain: what is it?
60 y/o male complains of sudden onset 60 y/o male complains of sudden onset tearing chest pain that went up into his tearing chest pain that went up into his jaw, through to his back, and then down jaw, through to his back, and then down into his abdomen. He also vomited once, into his abdomen. He also vomited once, is diaphoretic, and appears very anxious.is diaphoretic, and appears very anxious.
Vitals: BP 190/120 HR 110 RR 22 sPO2 Vitals: BP 190/120 HR 110 RR 22 sPO2 95%95%
Aortic DissectionAortic Dissection Occurs more often in men older than 40Occurs more often in men older than 40 HTN is the most common risk factorHTN is the most common risk factor Associated with cardiac surgery, bicuspid Associated with cardiac surgery, bicuspid
aortic valve, stimulant use, and traumaaortic valve, stimulant use, and trauma Age<40, associated with congenital Age<40, associated with congenital
heart disease, Marfan, Ehlers-Danlos, heart disease, Marfan, Ehlers-Danlos, and giant cell arteritisand giant cell arteritis
44% of pts with Marfan’s will develop an 44% of pts with Marfan’s will develop an aortic dissectionaortic dissection
Aortic DissectionAortic Dissection Type A – 62% of dissectionsType A – 62% of dissections
Involve the ascending aorta and are therefore Involve the ascending aorta and are therefore much more lethalmuch more lethal
Type B – 38% of dissectionsType B – 38% of dissections Do not involve the ascending aortaDo not involve the ascending aorta Pt more likely to be older, smoke, have chronic Pt more likely to be older, smoke, have chronic
lung disease, HTN, or atherosclerosislung disease, HTN, or atherosclerosis
Aortic Dissection - DiagnosisAortic Dissection - Diagnosis Labs - CBC, chem7, PT/PTT, type and cross, Labs - CBC, chem7, PT/PTT, type and cross,
CK-MB, troponinCK-MB, troponin ECG- exclude other dx, 15% may have ECG- exclude other dx, 15% may have
ischemic changes -> 3% dissect back and ischemic changes -> 3% dissect back and most commonly involve the RCA, may have most commonly involve the RCA, may have LVH or nonspecific ST or T wave changesLVH or nonspecific ST or T wave changes
CXR – abnormal in 80% but nonspecific CXR – abnormal in 80% but nonspecific findingsfindings
CT scan – test of choiceCT scan – test of choice TEE – limited by availability and operatorTEE – limited by availability and operator Aortography – no longer the test of choiceAortography – no longer the test of choice MRI- excellent test but limited by availability MRI- excellent test but limited by availability
and instability of the patientand instability of the patient
Aortic Dissection - Aortic Dissection - ManagementManagement
Opioids – decrease pain and sympathetic toneOpioids – decrease pain and sympathetic tone B blockers – esmolol and labetalolB blockers – esmolol and labetalol
decrease BP and HR to decrease shearing forces decrease BP and HR to decrease shearing forces Should be started first unless the pt is bradycardicShould be started first unless the pt is bradycardic
Nipride – vasodilator, used in conjunction with a Nipride – vasodilator, used in conjunction with a B blocker to maintain SBP 100-120B blocker to maintain SBP 100-120
Hypotensive pts – measure BP in all 4 Hypotensive pts – measure BP in all 4 extremities to make sure it is real, IVF/Blood, extremities to make sure it is real, IVF/Blood, immediately to ORimmediately to OR
Type A -> OR (27% mortality if treated Type A -> OR (27% mortality if treated surgically vs 56% if treated medically)surgically vs 56% if treated medically)
Type B uncomplicated – 10% mortality when Type B uncomplicated – 10% mortality when treated medically (32% mortality if complicated)treated medically (32% mortality if complicated)
Aortic Aortic Dissection – Dissection –
Any Questions?Any Questions?
Chest Pain – What is it?Chest Pain – What is it?22 y/o healthy male complains of chest and 22 y/o healthy male complains of chest and
back pain after forcing himself to vomit. back pain after forcing himself to vomit. He states he had food stuck in his chest He states he had food stuck in his chest while eating at Mongolian BBQ and then while eating at Mongolian BBQ and then forced himself to vomit for relief. He now forced himself to vomit for relief. He now says that his voice is hoarse, it hurts to says that his voice is hoarse, it hurts to breathe deep, and he is still very breathe deep, and he is still very nauseated. He tried to drink some water, nauseated. He tried to drink some water, but this only intensified the pain.but this only intensified the pain.
Vitals: HR 120 BP 130/90 RR 25 sPO2 97%Vitals: HR 120 BP 130/90 RR 25 sPO2 97%
Esophageal Rupture – Esophageal Rupture – Boerhaave’sBoerhaave’s
15% are spontaneous with the 15% are spontaneous with the remainder being iatrogenic from remainder being iatrogenic from endoscopy, NGT, ETT, combitube, endoscopy, NGT, ETT, combitube, foreign body…foreign body…
90% of spontaneous ruptures occur in 90% of spontaneous ruptures occur in the distal esophagusthe distal esophagus
DX - CXR, gastrograffin swallow, CTDX - CXR, gastrograffin swallow, CT ManagementManagement
IV antibioticsIV antibiotics NPO and likely NGTNPO and likely NGT Surgery consultSurgery consult
That was the short and That was the short and sweet of it, any questions?sweet of it, any questions?
Chest Pain – What is it?Chest Pain – What is it?26 y/o male c/o retrosternal, sharp CP, difficulty 26 y/o male c/o retrosternal, sharp CP, difficulty
breathing, pain when breathing deeply, and breathing, pain when breathing deeply, and worsening dyspnea tonight when he laid down to worsening dyspnea tonight when he laid down to sleep. He states that for the last week he has had sleep. He states that for the last week he has had URI symptoms and low grade fever, but now feels URI symptoms and low grade fever, but now feels that it has moved into his chest with the increasing that it has moved into his chest with the increasing pain and difficulty breathing.pain and difficulty breathing.
Vitals: HR 110 BP 110/80 RR 24 sPO2 98%Vitals: HR 110 BP 110/80 RR 24 sPO2 98%
Heart: tachycardic and regular, (+) pericardial rubHeart: tachycardic and regular, (+) pericardial rubLungs: CTA BLungs: CTA B
Bedside TTE is negative for effusionBedside TTE is negative for effusion
PericarditisPericarditis
PericarditisPericarditis Causes – infectious, injury/trauma, Causes – infectious, injury/trauma,
metabolic, systemic (RA), carcinoma, or metabolic, systemic (RA), carcinoma, or aortic dissectionaortic dissection
DX – clinical suspicion, ecg, echoDX – clinical suspicion, ecg, echo Echo – pericardial effusion and Echo – pericardial effusion and
tamponade are worrisome complications tamponade are worrisome complications -> pts should be put in obs or -> pts should be put in obs or hospitalizedhospitalized
Treatment – NSAIDS, steroids for pts Treatment – NSAIDS, steroids for pts who cannot tolerate NSAIDSwho cannot tolerate NSAIDS
THE END!THE END!
ANY QUESTIONS?ANY QUESTIONS?