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Life-Threatening Chest Pain: Understanding Etiology and Approach

Explore the various causes of chest pain, including life-threatening conditions like Acute Coronary Syndromes, Pulmonary Embolism, and Aortic Dissection. Learn how to differentiate between benign and dangerous causes, and understand the importance of prompt evaluation and treatment. Discover the key aspects of history taking and physical examination in assessing chest pain, along with the necessary diagnostic work-up and management strategies for conditions like NSTEMI, STEMI, and Pulmonary Embolism.

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Life-Threatening Chest Pain: Understanding Etiology and Approach

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Presentation Transcript

  1. CHEST PAIN

  2. Objectives • Describe various etiologies for chest pain • Review approach to chest pain • Focus on life threatening causes of Chest Pain.

  3. What are the 6 cause of chest pain that can kill?

  4. Chest Pain That Can Kill • Acute Coronary Syndromes • Pulmonary Embolism • Aortic Dissection • Esophageal Rupture • Pneumothorax • Pneumonia Various others: Pulmonary HTN, Myocarditis, Tamponade

  5. Common “benign” causes of chest pain?

  6. Benign Causes • Musculoskeletal • Esophagitis • Bronchitis (Chest Pain secondary to cough) • Recently placed nipple rings • “Non-Specific Chest Pain” * *Most common – means we don’t know, but it is not going to hurt you.

  7. As a general rule any chest pain is ischemic in origin until proven otherwise!

  8. History matters! • Location: Central, left, or right • Associated symptoms: SOB, sweating, nausea • Timing: Gradual or sudden onset • Provocation: What makes worse or better? • Quality: Visceral vs somatic • Radiation: Back, neck, arm • Severity: Scale of 1-10

  9. What are the key parts of the rest of the History?What can you get out of the pt in 4 minutes?

  10. The Rest of the History • Past medical history • Meds – Cardiac meds? Nitro? ASA? Plavix? Coumadin? • Allergies – Always important! • Social – Smoker? Alcoholic? Cocaine? • Family – Sudden Death? Early MI? DVT? PE?

  11. What are the key parts of the Physical?What can you exam in only 2 minutes?

  12. Key Emergency Physical • General Appearance • Vital Signs • Heart (Muffled? Regular? Fast?) • Lungs (Equal? Wet? Tympanitic?) • Neck (JVD?) • Abdomen (Distention?) • LL (Edema? calf tenderness?)

  13. Approach to Chest Pain INITIAL GOAL in ED is to identify life threats • MI, PE, aortic dissection Remember ABCs always first

  14. What do you do in the first 60 seconds?

  15. First 60 seconds • How does the pt look? • What are the pt’s vital signs? • EMS story?

  16. Next 5 minutes?What are 2 bedside tests to consider?What is an important and cheap medication you should consider?

  17. Next 5 Minutes • Brief History • Brief Physical (ABCs) . • What are 2 bedside tests that can be done to help stratify the pt? • EKG • Portable CXR • What is an important and cheap medication you should consider? • ASA (More on this later)

  18. Next 10 Minutes • Patient already stabilized, initial data gathered, and initial orders submitted • Secondary survey: More detailed history and physical exam • Address patient’s pain • Goal now is to categorize patient • Chest wall pain- Musculoskeletal • Pleuritic chest pain- Respiratory • Visceral chest pain- Cardiac

  19. Myocardial ischemia or infarction • Pressure-type of chest pain • Generally involves central to left-sided pain with radiation to jaw or arms • Exacerbated by activity, relieved with rest • Relieved with nitro SUBLINGUAL • Associated with nausea, diaphoresis, syncope, shortness of breath • Enquire about cardiac risk factors: age, sex, smoking history, diabetes, hypertension, hyperlipidemia, previous myocardial infarction and family history

  20. Work-up • E CG • CXR to look for signs of congestive heart failure • Cardiac enzymes: CK (will begin to rise 6 hours after infarct and remain elevated for 24-48 hours), troponin (will begin to rise 12 hours after infarct and remain elevated for 2 weeks). Need to follow serially if first set negative.

  21. NSTEMI

  22. STEMI

  23. Management Strategy for NSTEMI Initial therapy • Morphine for pain • Oxygen if hypoxic • Nitro spray/drip for pain • Aspirin

  24. Management Strategy for STEMI • Morphine, oxygen, nitro, aspirin • Beta blockers, Ace inhibitors • Early invasive strategy with either thrombolytic therapy or percutaneous coronary intervention (preferred)

  25. Pulmonary Embolus Risk Factors • Hypercoaguability • Malignancy, pregnancy, estrogen use, factor V Leiden, protein C/S deficiency • Venous stasis • Bedrest > 48 hours, recent hospitalization, long distance travel • Venous injury • Recent trauma or surgery

  26. PE Diagnosis • Symptoms • SOB or dyspnea- Present in 90% • Chest pain (pleuritic)- 66% of patients with PE • Cough • Sudden onset • Signs • Tachycardia > 100 beats per minute • Tachypnea > 20 breaths per minute • Hypoxia < 95% on RA (no other cause) • Lower extremity swelling

  27. PE Treatment • IV fluid to maintain blood pressure • Heparin (Will limit propagation but does not dissolve clot) • Unfractionated: 80 u/kg bolus, 18 h/kg/hr • Fractionated (Lovenox): 1 mg/kg SC BID • Fibrinolytics • Consider with large if pt is unstable • No study has shown survival benefit, but very difficult to study. • Alteplase 50–100 mg infused over 2–6 hrs, (bolus in severe shock)

  28. Pneumothorax • Can be asymptomatic or present with acute pleuritic chest pain and dyspnea • Primary pneumothorax predominantly in healthy young tall males • Due to trauma (MVA accidents – associated with rib fractures, iatrogenic – during line placement, thoracentesis) • Increased alveolar pressure from asthma or barotraumas (BiPAP, ventilator-associated) • Rupture of bleb in COPD patients

  29. Pneumothorax • Decreased expansion of chest • Decreased breath sounds and • Decreased tactile/vocal fremitus on side of pneumothorax • Hyperresonant percussion note • Usually easily confirmed by CXR

  30. Needle Decompression

  31. Aortic Dissection • Abrupt onset • The pain usually is described as ripping or tearing • Tearing or ripping pain that is felt in the intrascapular area • New diastolic murmur, asymmetrical pulses, and asymmetrical blood pressure measurements • Risk factors: HTN, Marfan syndrome, coarctation of aorta.. • Widened mediastinum on a portable anteroposterior (AP) radiograph • TEE considered diagnostic test of choice

  32. Aortic Dissection Diagnosis • CXR- Widened mediastinum, abnormal aortic knob, pleural effusions • Not sensitive (25% have wide mediastinums) • Chest CT- Very sensitive and specific • Quickly obtained • Must think about kidney + contrast • Angiography- Gold standard • Most reliable anatomy of dissection • Bedside US – evaluate aorta and look at heart to r/o tampanode.

  33. Aortic Management • Involve CT surgery early • Blood pressure control • Goal SBP 120-130 mmHg • Beta blockers are first line (Labetalol and Esmolol) • Can add vasodilators i.e. nitroprusside • Admission to ICU • Ascending dissections will need surgery • If dissection is only descending, management is only medical

  34. Key Points • Not every chest pain is MI, however every chest pain should be considered as ischemic until proven otherwise • A good history and physical exam may help with the diagnosis • EKG is the best single diagnostic test to help rule out MI

  35. Thank You

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