Chest Pain and Cardiac
Emergencies 2015
Chest Pain and Cardiac
Emergencies
Welcome
Chest Pain
Certainty
Simulation
Introduction
• Chest Pain is common
– 6 potentially lethal causes to remember
– Traditional approach (*full Hx) may be suboptimal
• Assessment and Management should focus on
– ABCDEFG and ECG
– IV access, M.O.N.A. (may not be right anymore)
– Senior review (#8500/mobile or Medical Registrar)
Approach – Traditional vs. Emergency
Life Threats
Serious Causes
Benign Causes
(Common)
Lethal Causes
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Myocardial Infarction (MI)
Pulmonary Embolism (PE)
Aortic Dissection (AD)
Pneumothorax (Tension Pneumothorax)
Pneumonia and Sepsis
Oesophageal Perforation
Myocardial Infarction
and the Acute Coronary
Syndromes
ECG
ECG 1
Acute Coronary
Syndrome
Assessment
Assessment
• Assessment
– DETECT ABC approach
• Pitfalls
– Elderly Patients are
often pain free
– MI patients may
have NO risk factors
Acute Coronary Syndromes (ACS)
Acute Coronary
Syndromes
STEMI
NSTEMI
UAP
(30%)
(25%)
(35%)
Atypical = Typical
Acute Coronary
Syndrome
Management
Management – MONA
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Morphine
Oxygen
Nitrate
Aspirin
– 0.1mg/kg IV and reassessment
– titrated to 94% (no longer routine)
– with care (avoid in RV infarction)
– have a high threshold for not giving
– low NNT and good safety profile
• Other (ABCDEFG)
– ACE Inhibitor, β Blockers, Clopidogrel & Prasugrel
– Don’t ever forget glucose (BSL)
– Fluids (often required in RV infarction)
Management
DOCUMENT
YOUR PLAN
CLEARLY
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Referral – “ISBAR”
COMMUNICATE
Page 8500 and/or Cath Lab Team (STEMI)
Your Registrar Consultant (in hours)
Medical Registrar (out of hours)
EFFICIENTLY
Intro - I am Andrew the Intern covering A5C
Situation and Background - I have Mrs Smith
who is in hospital with abdominal pain that
CLEARLY
was thought to be fromAND
Gallstones
– she now
has Chest pain & ST Elevation in AVF, II and III
• Assessment – obs Response – review
Management
• Resuscitation, Specific (MONA) and Supportive
• Disposition
– Catheter Laboratory
– Cardiac Unit (A5a, A5c)
– CCU (A5b)
– Cardiothoracics (C3c and D3c)
– Respiratory Ward - PE and Pneumothorax (B5a)
– ICU (E3a and E3b)
– Home & follow up (e.g. EST, Cardiac CT, MIBI, Echo)
Chest Pain
Risk Stratification and
State Policy
ALL PROTOCOLS
ARE ON ED
INTRANET
Other Causes
of Chest Pain
Pulmonary Embolism
Aortic Dissection
• Uncommon 5/100,000
• Overall Mortality is 27% in hospital,
1% per hour and >90% untreated
• Ratio of MI to Dissection is 3000:5 (so it i
s often missed and treated as MI)
• Risk Factors
– Hypertension, Cardiothoracic Surgery,
Collagen Vascular Disease
• Stanford – A & B (‘A’ proximal involvement)
• CXR and BP both arms have limited value!
Pneumothorax
Arrhythmia
Recognition and
Management
Has the patient arrested?
Perfusion
No Pulse
ALS
Algorithm
Pulse
Assessment
of Stability
Is the patient stable?
Are there any adverse signs?
Stability and
Adverse Signs
Extremes of
Heart Rate
*Blood Pressure
and Perfusion
Chest Pain
Signs of Acute
Heart Failure
Arrhythmias
• The Mantra / Approach
– How is the patient? What is the Cause?
– IV, O2, Monitor
– Call for assistance
• Assessment of Rhythm
– Assessment of Pulse and Adverse Features
– Narrow Complex vs. Broad Complex
– Regular vs. Irregular
– Slow, Fast vs. Very Fast
Causes of Bradycardia/Tachycardia?
Drugs
Ischaemia
Electrolytes
Take Home
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6 lethal causes
‘Atypical = Typical’ (Non-cardiac = Non-cardiac)
A – G approach
Serial ECGs
Call for senior help
Call for help (ALS team) for patients with adverse
signs including refractory chest pain, shock,
extremes of heart rate and cardiac failure