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CHEST PAINER June 16, 2009
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Stratification
RISK
Risk Factors
Who gets what?
List the risk factors
Clinical Suspicion
Testing
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Chief Complaint
What will bepresentingcomplaints?
MALE
FEMALE
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HPI
What are the KILLERS1. Myocardial infarction2. Dissecting aortic aneurysm
3. Pericarditis with tamponade4. PE5. Pneumonia6. Tension pneumothorax7. Rupture esophagus (Boorhaves syndrome)8. Cancer
What are the Most Commons
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Causes
Acute Coronary Syndrome
Aneurysm, Abdominal
Aneurysm, Thoracic
Angina Pectoris
Aortic Regurgitation
Aortic Stenosis
Atrial Fibrillation
Atrial Flutter
Cardiomyopathy, Dilated
Cardiomyopathy, Restrictive
Congestive Heart Failure andPulmonary Edema
Dissection, Aortic
Dissection, Carotid Artery
Dissection, Vertebral Artery
Heart Block, First Degree
Heart Block, Second Degree
Heart Block, Third Degree
Mitral Regurgitation
Mitral Stenosis
Mitral Valve Prolapse
Multifocal Atrial Tachycardia
Myocardial Infarction
Myocarditis
Myopathies
Congestive Heart Failure
Pericarditis and CardiacTamponade
Peripheral Vascular Disease
Premature VentricularContraction
Pulmonic Valvular Stenosis
Shock, Cardiogenic Hypovolemica
Sinus Bradycardia
Superior Vena Cava Syndrome
Syncope
Tetralogy of Fallot
Thoracic Outlet Syndrome
Torsade de Pointes
Transplants, Heart
Ventricular Tachycardia
Wolff-Parkinson-WhiteSyndrome
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http://emedicine.medscape.com/article/756979-overviewhttp://emedicine.medscape.com/article/756735-overviewhttp://emedicine.medscape.com/article/761627-overviewhttp://emedicine.medscape.com/article/761889-overviewhttp://emedicine.medscape.com/article/757146-overviewhttp://emedicine.medscape.com/article/757200-overviewhttp://emedicine.medscape.com/article/757370-overviewhttp://emedicine.medscape.com/article/757549-overviewhttp://emedicine.medscape.com/article/757668-overviewhttp://emedicine.medscape.com/article/757822-overviewhttp://emedicine.medscape.com/article/757999-overviewhttp://emedicine.medscape.com/article/757999-overviewhttp://emedicine.medscape.com/article/756835-overviewhttp://emedicine.medscape.com/article/757906-overviewhttp://emedicine.medscape.com/article/761451-overviewhttp://emedicine.medscape.com/article/758322-overviewhttp://emedicine.medscape.com/article/758383-overviewhttp://emedicine.medscape.com/article/758454-overviewhttp://emedicine.medscape.com/article/758816-overviewhttp://emedicine.medscape.com/article/758899-overviewhttp://emedicine.medscape.com/article/759004-overviewhttp://emedicine.medscape.com/article/759135-overviewhttp://emedicine.medscape.com/article/759321-overviewhttp://emedicine.medscape.com/article/759212-overviewhttp://emedicine.medscape.com/article/759487-overviewhttp://emedicine.medscape.com/article/761722-overviewhttp://emedicine.medscape.com/article/759642-overviewhttp://emedicine.medscape.com/article/759642-overviewhttp://emedicine.medscape.com/article/761556-overviewhttp://emedicine.medscape.com/article/761148-overviewhttp://emedicine.medscape.com/article/761148-overviewhttp://emedicine.medscape.com/article/759890-overviewhttp://emedicine.medscape.com/article/759992-overviewhttp://emedicine.medscape.com/article/760145-overviewhttp://emedicine.medscape.com/article/760220-overviewhttp://emedicine.medscape.com/article/760301-overviewhttp://emedicine.medscape.com/article/811669-overviewhttp://emedicine.medscape.com/article/760387-overviewhttp://emedicine.medscape.com/article/760477-overviewhttp://emedicine.medscape.com/article/760667-overviewhttp://emedicine.medscape.com/article/761249-overviewhttp://emedicine.medscape.com/article/760963-overviewhttp://emedicine.medscape.com/article/761066-overviewhttp://emedicine.medscape.com/article/761066-overviewhttp://emedicine.medscape.com/article/761066-overviewhttp://emedicine.medscape.com/article/761066-overviewhttp://emedicine.medscape.com/article/761066-overviewhttp://emedicine.medscape.com/article/761066-overviewhttp://emedicine.medscape.com/article/761066-overviewhttp://emedicine.medscape.com/article/761066-overviewhttp://emedicine.medscape.com/article/760963-overviewhttp://emedicine.medscape.com/article/761249-overviewhttp://emedicine.medscape.com/article/760667-overviewhttp://emedicine.medscape.com/article/760477-overviewhttp://emedicine.medscape.com/article/760387-overviewhttp://emedicine.medscape.com/article/811669-overviewhttp://emedicine.medscape.com/article/760301-overviewhttp://emedicine.medscape.com/article/760220-overviewhttp://emedicine.medscape.com/article/760145-overviewhttp://emedicine.medscape.com/article/760145-overviewhttp://emedicine.medscape.com/article/759992-overviewhttp://emedicine.medscape.com/article/759890-overviewhttp://emedicine.medscape.com/article/761148-overviewhttp://emedicine.medscape.com/article/761148-overviewhttp://emedicine.medscape.com/article/761556-overviewhttp://emedicine.medscape.com/article/759642-overviewhttp://emedicine.medscape.com/article/759642-overviewhttp://emedicine.medscape.com/article/761722-overviewhttp://emedicine.medscape.com/article/759487-overviewhttp://emedicine.medscape.com/article/759212-overviewhttp://emedicine.medscape.com/article/759321-overviewhttp://emedicine.medscape.com/article/759135-overviewhttp://emedicine.medscape.com/article/759004-overviewhttp://emedicine.medscape.com/article/758899-overviewhttp://emedicine.medscape.com/article/758816-overviewhttp://emedicine.medscape.com/article/758454-overviewhttp://emedicine.medscape.com/article/758383-overviewhttp://emedicine.medscape.com/article/758322-overviewhttp://emedicine.medscape.com/article/761451-overviewhttp://emedicine.medscape.com/article/757906-overviewhttp://emedicine.medscape.com/article/756835-overviewhttp://emedicine.medscape.com/article/757999-overviewhttp://emedicine.medscape.com/article/757999-overviewhttp://emedicine.medscape.com/article/757822-overviewhttp://emedicine.medscape.com/article/757668-overviewhttp://emedicine.medscape.com/article/757549-overviewhttp://emedicine.medscape.com/article/757370-overviewhttp://emedicine.medscape.com/article/757200-overviewhttp://emedicine.medscape.com/article/757146-overviewhttp://emedicine.medscape.com/article/761889-overviewhttp://emedicine.medscape.com/article/761627-overviewhttp://emedicine.medscape.com/article/756735-overviewhttp://emedicine.medscape.com/article/756979-overview7/31/2019 PA 650 Chest Pain June 2012
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Pulmonary
Pulmonary
Asthma
Bronchitis
Chronic Obstructive Pulmonary Disease and Emphysema
Hyperventilation Syndrome Pleural Effusion
Pneumonia, Aspiration
Pneumonia, Bacterial
Pneumonia, Empyema and Abscess
Pneumonia, Immunocompromised
Pneumonia, Mycoplasma
Pneumonia, Viral
Pneumothorax, Iatrogenic, Spontaneous and Pneumomediastinum
Pulmonary Embolism
Pleuritic CP
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http://emedicine.medscape.com/article/806890-overviewhttp://emedicine.medscape.com/article/807035-overviewhttp://emedicine.medscape.com/article/807143-overviewhttp://emedicine.medscape.com/article/807277-overviewhttp://emedicine.medscape.com/article/807375-overviewhttp://emedicine.medscape.com/article/807600-overviewhttp://emedicine.medscape.com/article/807707-overviewhttp://emedicine.medscape.com/article/807499-overviewhttp://emedicine.medscape.com/article/807846-overviewhttp://emedicine.medscape.com/article/807927-overviewhttp://emedicine.medscape.com/article/808013-overviewhttp://emedicine.medscape.com/article/808162-overviewhttp://emedicine.medscape.com/article/759765-overviewhttp://emedicine.medscape.com/article/759765-overviewhttp://emedicine.medscape.com/article/759765-overviewhttp://emedicine.medscape.com/article/759765-overviewhttp://emedicine.medscape.com/article/759765-overviewhttp://emedicine.medscape.com/article/808162-overviewhttp://emedicine.medscape.com/article/808013-overviewhttp://emedicine.medscape.com/article/807927-overviewhttp://emedicine.medscape.com/article/807846-overviewhttp://emedicine.medscape.com/article/807499-overviewhttp://emedicine.medscape.com/article/807707-overviewhttp://emedicine.medscape.com/article/807600-overviewhttp://emedicine.medscape.com/article/807375-overviewhttp://emedicine.medscape.com/article/807277-overviewhttp://emedicine.medscape.com/article/807143-overviewhttp://emedicine.medscape.com/article/807035-overviewhttp://emedicine.medscape.com/article/806890-overview7/31/2019 PA 650 Chest Pain June 2012
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Musculoskeletal
Chest Wall Pain
11-50 %
Trauma
Costochondritis
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Other
Psychological
GI Related GERD
Undifferentiated
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ROS
Killers
Cardio
Pulmonary
Associations to DD
Claudication (PAD) increased risk of CAD
Most Common
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Past Medical History
Surgical History
Specifically ask about other disease processes
that increase the risk of whatever you areconcerned about DM
HTN
When was the last time you saw a doctor? Have you ever seen a doctor for blood pressure,
cholesterol, or your heart ?
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Medications & Allergies
Meds that alert you to increased risk
New Meds Antacids, ASA, when & why did you start taking
that medication
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Family History
Tell me about your (mother, father, brothers,sisters) health
Specifically CAD, PAD, Age when problemsstarted or death
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Social History
Occupation Stress
Tobacco Pack years
Alcohol
Do you use any street drugs
If you want to know about Marijuana ? ASK ABOUT COCAINE (re: B-Blocker)
UDS? Unopposed alpha receptors Auto maticallydo a drug screen
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Physical Exam
Vitals and EKG
Constitutional
Skin (xanthoma, splinter hemorrhages) Head
Eyes (copper wire)
ENT (ear creases)
Neck
Heart
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Physical Exam
Lungs
Abdomen
GU (not examined) Musculoskeletal / Extremities
Neuro
Heme-Lymph
Psychiatric (anxious)
Endocrine (thyroid, DM)
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Differential
List 10
Think about the HALMARKS of those ten
Have you asked questions or performed aphysical exam that includes or excludes these
If not what test do you need to Confirm your suspected diagnosis
Exclude the KILLERS
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ER Lab orders
CBC
BMP
LFT if indicated
Lipase
CIP Cardiac Enzymes
PTT/PTT/ INR You need all three (unlike monitoring warfarin)
BNP
D-Dimer (=/-)
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ER Orders
Radiology Chest x-ray
What are you looking for? If you think chest pain is muscle pain are not getting a CT
CT Scan-not used in everyone- if think they arehaving N, CT PE Study (CT Pulmonary Angiogram) CT Angiogram of the Aorta CT Angiogram of the Heart-specialized scanner
CT TRIPLE RULE OUT-aorta angiogram abd aortaangiogram out PE
Other test as indicated to rule out differentials
Pts are taken to cath lab every day on sxs alone.They are not done emergency, price $1500
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ER Medication Orders
ASA ON ARRIVAL
If EKG changes that indicate MI or Angina, or High ClinicalSuspicion go right to the ACS PROTOCOL and Notify
Cardiology Remember CXR BEFORE Starting Heaprin https://www.musc.edu/cce/ORDFRMS/pdf/cpedadmit.pdf https://www.musc.edu/cce/ORDFRMS/pdf/ah_card_cardiologyhe
parinprotocol.pdf
Nitroglycerine (based on suspicion) 0.4 mg SL-see if it helps pain can also help with esophageal pain
as well 1-2 inches of paste to chest IV Infusion (drip) 5 or 10 micrograms / min
You will titrate this to pain AND BP or hypotensive
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https://www.musc.edu/cce/ORDFRMS/pdf/cpedadmit.pdfhttps://www.musc.edu/cce/ORDFRMS/pdf/ah_card_cardiologyheparinprotocol.pdfhttps://www.musc.edu/cce/ORDFRMS/pdf/ah_card_cardiologyheparinprotocol.pdfhttps://www.musc.edu/cce/ORDFRMS/pdf/ah_card_cardiologyheparinprotocol.pdfhttps://www.musc.edu/cce/ORDFRMS/pdf/ah_card_cardiologyheparinprotocol.pdfhttps://www.musc.edu/cce/ORDFRMS/pdf/cpedadmit.pdf7/31/2019 PA 650 Chest Pain June 2012
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ER Chest Pain Workup
Oxygen
Nitroglycerine (based on suspicion)
0.4 mg GI Cocktail
EKG
CXR CMB, BMP, Trop, INR, UDS, D-Dimer
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Delta (change)
An approach using the change in biomarkers over two hours wasinvestigated in a comprehensive strategy of chest pain testing.There was a 93 percent sensitivity for acute myocardial infarctionwithin 24 hours using a two hour strategy incorporating baselineECG, cardiac markers, two hour delta CK-MB, two hour delta
troponin and serial ECGs
In a similar investigation, delta CK-MB was more accurate thanmyoglobin for diagnosing early myocardial infarction.
However, the sensitivity of the delta CK-MB varied from 73 to 93percent depending on the cutoff used, emphasizing theimportance of using an appropriate threshold for a positivechange
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Now What?
When you have positive findings its easy
What if everything is normal-what do you do, a lot is clinicalsuspicion, we can call cardiologist and see if they will hold
overnight and stress test the pt. PA may stress them and theysend them to
Admit-If having a stemi, unstable angina
Discharge Medicine follow up Cardiology follow up
____ hrs. observation
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Should I stay or should I go?
CP with identified cause
Depend on the cause
CP with ekg changes CP 1 risk factor
CP 2 risk factors
CP 3 risk factors CP 4 risk factors
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Escalating the outpatient
workup
H &P / Risk factors
REVIEW OF RECORDS EKG & CXR
Compare to previous
Early pathology may not show up
Resting EKG Functional testing
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Functional Testing
Stress
Walking or nuclear
Stress echo
Wall motion abnormality
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Cardiac Catheterization
Virtual
TRO
heart center
Real
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Outpatient
Stress Testing
Holter Monitor (24-48 hrs)
Event Monitor (30 days) Tilt Table-look up
EP Studies-look up
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Observation
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