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Evaluation of chest pain
1.
2. Causes of chest pain that cause immediate threat to
life:
Acute coronary syndrome
Aortic dissection
Pulmonary embolism
Tension pneumothorax
Pericardial tamponade
Mediastinisis ( esophageal rupture)
3. Acute coronary syndrome:
Leading cause of death in adults
Results from atherosclerotic plaque rupture &
thrombus formation
Coronary blood flow is reduced & myocardial
ischemia occurs
Degree & duration of oxygen supply-demand
mismatch determines whether pt. develops
myocardial ischemia with or without injury
4. Aortic dissection:
Commonly affects pts with systemic HTN
Begins as tear in inner layer of aortic wall allowing
blood to track b/w intima & media causing
subsequent obstruction of branches of arteries &
ischemic injury
Pulmonary embolism:
Occurs when dislodged venous clot migrates through
rt.side of heart & gets lodged at branch pt. of pul.
Arteries
Occlusion results in pul.HTN, rt.venticular
dysfunction, poor gas exchange, parechymal
infarction
Mediastinitis:
Common causes include odontogenic infection,
esophageal perforation, iatrogenic complications
of cardiac surgery or upper GI or airway
procedures
5. Pneumothorax:
Can occur following trauma or pul.procedures
Also occurs spontaneously in pts with or without
underlying lung disease
Accumulation of air in pleural space can lead to
tension pneumothorax with compression on
mediastinum causing rapid clinical deterioration &
death
Pericardial tamponade:
Occurs when there is accumulation of pericardial
fluid under pressure leading to impaired filling
producing picture resembling cardiogenic shock
Can occur following aortic dissection, thoracic
trauma, acute pericarditis,malignancy,uremia etc
9. History: obtain detailed history of:
onset of pain
Provocation/ palliation
Quality of pain
Radiation
Site of pain
Timing
Prior diagnostic studies for similar studies or prior
studies
Associated symptoms
h/o HTN, DM, PVD,malignancy
h/o recent events-trauma, major surgery or
medical procedures, period of immobilization
h/o use of cigarettes, cocaine etc
10. Ancillary studies:
Electrocardiogram:
best immediately available test for detecting
ACS
should be repeated as frequently as every 10 min
if initial ECG is not diagnostic & there is high
suspiscion of AMI
Limited value in pul. Embolism
Tamponade- ECG findings shows low voltage &
electrical alterans
Pericarditis: mimic AMI & vary as disease
progresses. PR segment depression, ST segment
elevation & T wave inversion
Aortic dissection: completely normal to ST
segment elevation
11. Laboratory studies:
Cardiac biomarkers:
Cardiac troponin I: In AMI elevates within 3 hrs, peaks
at 12 hrs & remains elevated for 7-10 days
Creatine kinase MB- raise to twice normal at 6 hrs &
peaks app. 24 hrs
D- dimer:
Among pts with low pretest probability for
pul.embolus, this test with high sensitivity can rule
out diagnosis
Pts likely to have elevated D-dimer at baseline are
elderly, malignancy, sepsis, recent trauma or surgery
can rule out aortic dissection
12. Complete blood count:
WBC count may be raised in inflammatory or
infectious conditions
Anemia in pts with exertional chest pain-suggestive
of myocardial ischemia
B-type natriuretic peptide:
Levels >100pg/ml are sensitive for acute heart
failure & levels < 50 have negative predictive
value for HF
Arterial blood gas:
For diagnosing or excluding pul.embolism
Not routinely indicated
13. Chest radiography:
Indicated in all chest pain pts with hemodynamic
instability or potentially life threatening diagnosis
Aortic dissection-widened mediastinum or aortic
knob
Pul.embolism- normal or nonspecific
Pneumonia & pneumothorax- diagnosed by CXR
Acute heart failure-pul.vascular congestion &
cardiomegaly
In pts with severe vomiting or recent
instrumentation of esophagus, mediastinal
emphysema & pleural effusion suggest esophageal
tear
14. Other imaging:
Aortic dissection: CT, MRI, transesophageal
echocardiography
Pulmonary embolism: CT, nuclear imaging or
pul. Angiography
Pul.angiography combined with venography can
detect DVT
Nuclear cardiac imaging: exercise stress test with
or without nuclear imaging as well as stress
echocardiography can assist in risk stratification
Bedside ultrasonography:helps to exclude or
support certain diagnosis
Used to assess pts with blunt trauma for
effusions,tamponade,wall motion
abnormalities,valvular & septal abnormalities etc
15. Assessment & stabilization of airway, breathing &
circulation
Acute coronary syndrome:
requires serial ECG’s
Pts with STEMI-require immediate
revascularization or fibrinolysis
Aortic dissection:
Emergent treatment-BP & HR control to reduce
force & intensity of cardiac flow
Best achieved with combination of beta-blockers
(esmolol)&Na nitroprusside(or nitroglycerin)
Beta-blockers should be started first to prevent
rebound tachycardia
16. Pulmonary embolism:
Initial management-anticoagulation
Pts with massive or submassive emboli require
thrombolytics or embolectomy
Pneumothorax:
Tension pneumothorax-immediate tube or needle
thoracostomy
Pericardial tamponade:
Tamponade with overt hemodynamic compromise
requires removal of pericardial fluid
Early tamponade with mild hemodynamic
compromise may be treated conservatively with
careful monitoring
17. Mediastinitis:
Broad spectrum antibiotics -in suspected
mediastinitis
If required-surgical debridement & possible repair
Disposition:
Pt with hemodynamic instability or respiratory
distress-admitted in ICU
Pts with aortic dissection, pneumothorax, cardiac
tamponade, & mediastinitis require admission
Pts with pul.emboli with hemodynamic instability,
STEMI ,high risk of ACS-admitted in ICU
pts with stable angina-do not require inpatient
evaluation