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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
- 14. ANTEROSEPTAL
- 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
- 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
- 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
- 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