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AN APPROACH TO
ACUTE CHEST PAIN
THE FIRST 20 MINUTES
COMPLAINS
OF ACUTE
CHEST PAIN,
WHAT DO
YOU DO?
YOUR PT IS TRIAGED
AS A RED CODE
THATS A
LONG ALGORITHM!!!
OUR JOB IS TO STABILISE
THEN TO STRATIFY INTO A RISK CATEGORY
ALTHOUGH NOT FOOLPROOF IT IS INVALUABLE
OUR MAIN WEAPON IS THE ECG
• ONCE WE HAVE AN ECG IT LEADS US DOWN THREE DISTINCT
PATHS
• WE WILL ATTEMPT TO LOOK AT SIMPLE ECG TRACINGS AND
IDENTIFY WORRYING TRAITS
• INTERPRETING ECGS IS AN ESSENTIAL SKILL FOR ALL
DOCTORS
• BOOKS SUCH AS ‘ECG MADE EASY’ OR ‘THE ONLY ECG BOOK
YOU WILL EVER NEED’ ARE EASILY AVAILABLE ONLINE
ST ELEVATION
MYOCARDIAL INFARCT
CAN YOU NAME THE ABNORMALITIES IN THE ECG?
WHICH PARTS OF THE HEART HAVE SUFFERED AN INFARCT?
SHOULD I BE WORRIED?
CAN YOU NAME THE ABNORMALITIES IN THE ECG?
WHICH PARTS OF THE HEART HAVE SUFFERED AN INFARCT?
SHOULD I BE WORRIED?
WHAT NEXT?
SO NOW WE’VE MADE THE DIAGNOSIS
• THIS IS A HIGH RISK ACS
• THE PT REQUIRES EITHER PCI OR THROMBOLYSIS
• HOW MUCH OF MORPHINE CAN WE GIVE?
• BETWEEN 2-10MG DEPENDING ON
RESPONSE
• WHY IS THE MORPHINE SO IMPORTANT?
• PAIN AND CATECHOLAMINE DECREASE
THIS IS THE POINT YOU INVOLVE THE PHYSICIANS
THE PATIENT IDEALLY NEEDS URGENT REPERFUSION
• WE DO NOT NEED TO WAIT
FOR CARDIAC MARKERS
• WHAT DO I ASK THE
PATIENT ABOUT?
• HOW DO I PRESENT THE PT
TO THE PHYSICIAN?
JUST SOME GENERAL GUIDES
INTERPRETING AN ECG
• FIRST DETERMINE THE AXIS
• THEN THE RATE
• THEN THE RHTHYM
• THEN LOOK FOR CHANGES AND ABNORMALITIES
LETS TRY AND NAME
SOME INFARCTS
ANTEROSEPTAL
MORE OF A SEPTAL MI.
NOTE THE T-WAVE INVERSIONS.
DO WE NEED THE PATIENTS AGE AND GENDER?
• WHEN WE LOOK AT V2 AND V3 THESE ARE SPECIAL
CONSIDERATIONS
• IN WOMEN > 1.5 BLOCKS IS WORRYING
• IN MEN ITS WORRYING IF
• > 40 YEARS, 2 BLOCKS
• < 40 YEARS , 2.5 BLOCKS
INFERIOR MI
IS THERE RIGHT VENTRICULAR SPREAD?
AS A RULE OF THUMB, IF THE ST ELEVATION IN III >II, THEN YES
BUT YOU HAVE TO DO A 16 LEAD ECG TO CONFIRM!
HOW TO PLACE THE
ELECTRODES
WE CAN SEE THE
ST ELEVATION MUCH
BETTER NOW
POSTERIOR MI, ALONG WITH INFERIOR
AND RV
WE CONFIRM WITH AN 18 LEAD ECG
IT VERY RARELY OCCURS IN ISOLATION
WE CAN SEE THE ST ELEVATIONS
NOW V7-V9
AND NOW NSTEMI AND
UNSTABLE ANGINA
IS OUR PT
HIGH RISK
OR LOW
RISK?
WE CONCENTRATE
MAINLY ON 9 & 10
WE NEED TO CONSIDER EACH PT
IT DEPENDS
• IS THE PT UNSTABLE? - HIGH RISK
• ARE THERE DYNAMIC CHANGES IN THE ECG? - HIGH RISK
• ARE THE CARDIAC MARKERS RISING OR ELEVATED INITIALLY? -HIGH RISK
• IS THE PT DETERIORATING IN OUR CARE?
• TACHYCARDIAS
• HEART FAILURE
• PERSISTENT PAIN
• HAEMODYNAMIC INSTABILITY
• ALL POINT TOWARDS HIGH RISK
THEY ARE MANAGED AS STEMI PTS
IF OUR PT IS HIGH RISK?
• AND LOW RISK PATIENTS
REQUIRE FURTHER
EVALUATION BY A
CARDIOLOGIST
• THEY MUST NEVER BE SENT
HOME
• THEY REQUIRE SERIAL ECGS
AND CARDIAC MARKERS
• ALWAYS GIVE THEM LOW
DOSE MORPHINE ONLY, 2-5MG
AND NOT MORE, AND ONLY IF
TNT IS NOT CONTROLLING SXS
BUT IT SOUNDS LIKE CARDIAC PAIN
AND THE LOW RISK PT
• FIRST, HAVE I CONSIDERED ALTERNATE DIAGNOSIS?
• PERICARDITIS
• DISECTING ANEURYSM
• OESOPHAGEAL RUPTURE
• PULMONARY EMBOLI OR PNEUMOTHORAX
• SECOND, IF YOU ARE STRONGLY SUSPICIOUS OF A CARDIAC CAUSE,
THEN ADMIT FOR SERIAL ECGS AND CARDIAC MARKERS
• MANY MI’S SHOW NO ECG CHANGES
• CARDIAC MARKERS TAKE TIME TO RISE
JUST A FEW LAST THINGS
TO NOTICE ON THE ECG
ST ELEVATION IN AVR IS ALSO VERY, VERY WORRYING
BI PHASIC T-WAVES IN V2-V3
SHOULD MAKE YOU SUSPECT
A SERIOUS MI EVEN IF THE
PATIENT IS PAIN FREE
CAN YOU MAKE THE DIAGNOSIS?
WINNER IS EMPLOYEE OF THE MONTH!!
BE SYSTEMATIC,
NAME ALL THE CHANGES
THIS IS A PULMONARY EMBOLUS
LOOK OUT FOR
1)TACHYCARDIA 2) RBBB
3) S1Q3T3 PATTERN
4)T-WAVE INVERSIONS V2-V3
5) R-AXIS DEVIATION (NOT SEEN HERE)
OUR FIRST 20 MINUTES ARE CRITICAL
IN CONCLUSION
• AT THE VERY LEAST YOU
CAN GET AN ECG AND
STRATIFY YOUR PATIENT
• YOU CAN START THE
PROCESS OF SAVING YOUR
PATIENT
• IT IS IMPOSSIBLE TO TEACH
YOU THE SUBTLETIES OF
ECGS IN THESE FEW
SLIDES, BUT AT LEAST YOU
CAN RECOGNISE OBVIOUS
PATTERNS
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Chest pain pdf

  • 1. AN APPROACH TO ACUTE CHEST PAIN THE FIRST 20 MINUTES
  • 2. COMPLAINS OF ACUTE CHEST PAIN, WHAT DO YOU DO? YOUR PT IS TRIAGED AS A RED CODE
  • 4. OUR JOB IS TO STABILISE THEN TO STRATIFY INTO A RISK CATEGORY
  • 5. ALTHOUGH NOT FOOLPROOF IT IS INVALUABLE OUR MAIN WEAPON IS THE ECG • ONCE WE HAVE AN ECG IT LEADS US DOWN THREE DISTINCT PATHS • WE WILL ATTEMPT TO LOOK AT SIMPLE ECG TRACINGS AND IDENTIFY WORRYING TRAITS • INTERPRETING ECGS IS AN ESSENTIAL SKILL FOR ALL DOCTORS • BOOKS SUCH AS ‘ECG MADE EASY’ OR ‘THE ONLY ECG BOOK YOU WILL EVER NEED’ ARE EASILY AVAILABLE ONLINE
  • 7. CAN YOU NAME THE ABNORMALITIES IN THE ECG? WHICH PARTS OF THE HEART HAVE SUFFERED AN INFARCT? SHOULD I BE WORRIED?
  • 8. CAN YOU NAME THE ABNORMALITIES IN THE ECG? WHICH PARTS OF THE HEART HAVE SUFFERED AN INFARCT? SHOULD I BE WORRIED?
  • 9. WHAT NEXT? SO NOW WE’VE MADE THE DIAGNOSIS • THIS IS A HIGH RISK ACS • THE PT REQUIRES EITHER PCI OR THROMBOLYSIS • HOW MUCH OF MORPHINE CAN WE GIVE? • BETWEEN 2-10MG DEPENDING ON RESPONSE • WHY IS THE MORPHINE SO IMPORTANT? • PAIN AND CATECHOLAMINE DECREASE
  • 10. THIS IS THE POINT YOU INVOLVE THE PHYSICIANS THE PATIENT IDEALLY NEEDS URGENT REPERFUSION • WE DO NOT NEED TO WAIT FOR CARDIAC MARKERS • WHAT DO I ASK THE PATIENT ABOUT? • HOW DO I PRESENT THE PT TO THE PHYSICIAN?
  • 11. JUST SOME GENERAL GUIDES INTERPRETING AN ECG • FIRST DETERMINE THE AXIS • THEN THE RATE • THEN THE RHTHYM • THEN LOOK FOR CHANGES AND ABNORMALITIES
  • 12. LETS TRY AND NAME SOME INFARCTS
  • 13.
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  • 16. MORE OF A SEPTAL MI. NOTE THE T-WAVE INVERSIONS. DO WE NEED THE PATIENTS AGE AND GENDER?
  • 17. • WHEN WE LOOK AT V2 AND V3 THESE ARE SPECIAL CONSIDERATIONS • IN WOMEN > 1.5 BLOCKS IS WORRYING • IN MEN ITS WORRYING IF • > 40 YEARS, 2 BLOCKS • < 40 YEARS , 2.5 BLOCKS
  • 18.
  • 19. INFERIOR MI IS THERE RIGHT VENTRICULAR SPREAD? AS A RULE OF THUMB, IF THE ST ELEVATION IN III >II, THEN YES BUT YOU HAVE TO DO A 16 LEAD ECG TO CONFIRM!
  • 20. HOW TO PLACE THE ELECTRODES WE CAN SEE THE ST ELEVATION MUCH BETTER NOW
  • 21.
  • 22. POSTERIOR MI, ALONG WITH INFERIOR AND RV WE CONFIRM WITH AN 18 LEAD ECG IT VERY RARELY OCCURS IN ISOLATION
  • 23. WE CAN SEE THE ST ELEVATIONS NOW V7-V9
  • 24. AND NOW NSTEMI AND UNSTABLE ANGINA
  • 25. IS OUR PT HIGH RISK OR LOW RISK? WE CONCENTRATE MAINLY ON 9 & 10
  • 26. WE NEED TO CONSIDER EACH PT IT DEPENDS • IS THE PT UNSTABLE? - HIGH RISK • ARE THERE DYNAMIC CHANGES IN THE ECG? - HIGH RISK • ARE THE CARDIAC MARKERS RISING OR ELEVATED INITIALLY? -HIGH RISK • IS THE PT DETERIORATING IN OUR CARE? • TACHYCARDIAS • HEART FAILURE • PERSISTENT PAIN • HAEMODYNAMIC INSTABILITY • ALL POINT TOWARDS HIGH RISK
  • 27. THEY ARE MANAGED AS STEMI PTS IF OUR PT IS HIGH RISK? • AND LOW RISK PATIENTS REQUIRE FURTHER EVALUATION BY A CARDIOLOGIST • THEY MUST NEVER BE SENT HOME • THEY REQUIRE SERIAL ECGS AND CARDIAC MARKERS • ALWAYS GIVE THEM LOW DOSE MORPHINE ONLY, 2-5MG AND NOT MORE, AND ONLY IF TNT IS NOT CONTROLLING SXS
  • 28. BUT IT SOUNDS LIKE CARDIAC PAIN AND THE LOW RISK PT • FIRST, HAVE I CONSIDERED ALTERNATE DIAGNOSIS? • PERICARDITIS • DISECTING ANEURYSM • OESOPHAGEAL RUPTURE • PULMONARY EMBOLI OR PNEUMOTHORAX • SECOND, IF YOU ARE STRONGLY SUSPICIOUS OF A CARDIAC CAUSE, THEN ADMIT FOR SERIAL ECGS AND CARDIAC MARKERS • MANY MI’S SHOW NO ECG CHANGES • CARDIAC MARKERS TAKE TIME TO RISE
  • 29. JUST A FEW LAST THINGS TO NOTICE ON THE ECG
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  • 33. ST ELEVATION IN AVR IS ALSO VERY, VERY WORRYING
  • 34. BI PHASIC T-WAVES IN V2-V3 SHOULD MAKE YOU SUSPECT A SERIOUS MI EVEN IF THE PATIENT IS PAIN FREE
  • 35. CAN YOU MAKE THE DIAGNOSIS? WINNER IS EMPLOYEE OF THE MONTH!! BE SYSTEMATIC, NAME ALL THE CHANGES
  • 36. THIS IS A PULMONARY EMBOLUS LOOK OUT FOR 1)TACHYCARDIA 2) RBBB 3) S1Q3T3 PATTERN 4)T-WAVE INVERSIONS V2-V3 5) R-AXIS DEVIATION (NOT SEEN HERE)
  • 37. OUR FIRST 20 MINUTES ARE CRITICAL IN CONCLUSION • AT THE VERY LEAST YOU CAN GET AN ECG AND STRATIFY YOUR PATIENT • YOU CAN START THE PROCESS OF SAVING YOUR PATIENT • IT IS IMPOSSIBLE TO TEACH YOU THE SUBTLETIES OF ECGS IN THESE FEW SLIDES, BUT AT LEAST YOU CAN RECOGNISE OBVIOUS PATTERNS