APPROACH TO CHEST PAIN
DR. PRAKASH MOHANASUNDARAM
EMERGENCY PHYSICIAN
Department of Accident, Emergency & Critical Care Medicine.
Vinayaka Mission Kirupananda Variyar Medical college Hospital,
Salem, Tamilnadu, India.
www.emergencymedicineindia.com
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BACKGROUND
 Approx 5% of all ED visits
 15% - AMI
 25-30% - Unstable angina
 14 -34% - Other conditions
 Atypical presentations – common
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ACUTE CHEST PAIN
• Recent onset, typically less than 24 h
• Location described on the anterior thorax
• A noxious uncomfortable sensation distressing
to the patient.
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CATEGORISATION
• Visceral pain
• Pleuritic pain
• Chest wall pain
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Typical exertional angina
Atypical angina
Unstable angina
Acute myocardial infarction
Aortic dissection
Pericarditis
Oesophageal reflux or spasm
Oesophageal rupture
Mitral valve prolapse
VISCERAL
PAIN
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Pulmonary embolism
Pneumonia
Spontaneous pneumothorax
Pericarditis
Pleurisy
PLEURITIC
PAIN
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Costosternal syndrome
Costochondritis
Precordial catch syndrome
Slipping rib syndrome
Xiphodynia
Radicular syndromes
Intercostal nerve syndromes
Fibromyalgia
CHEST
WALL
PAIN
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Etiology
Quality
Location
Radiation
Dura Asso.
Asso.Symptom Onset
tion Symptoms
s
MI
MI
visceral
retrosternal Neck
jaw
shoulder
arm
>15
min
Nausea,
vomiting,
diaphoresis,
dyspnoea
variable
angina
Angina
visceral
retrosternal Neck,
Jaw
shoulder,
arm
<15
min
Nausea,
vomiting,
diaphoresis,
dyspnoea
gradual
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Etiology
Quality
Aortic
severe
dissection
Location
Asso.
Symptoms
Onset
Sudden
retroster Inter
constant Nausea
diaphoresi
nal
scapular
s,
tearing
dyspnoea
pleuritic
lateral
Pneumot pleuritic
horax
lateral
PE
Radiation Duration
Neck,
back
constant dyspnoea
sudden
constant dyspnoea
sudden
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SCENARIO - 1
• 40 year old gentleman comes to ER with h/o
chest pain, breathlessness, sweating since 2 hrs
• Chest pain retrosternal, crushing type, non
radiating lasting for 2 hrs
• H/O hypertension for the past 3 years,
• Known smoker and a genetic h/o heart disease.
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VITALS
•
•
•
•
BP-110/60
HR-104
RR-34
SPO2-95%
•
•
•
•
CVS – Tachycardia
RS - Tachypnoea
PA - Soft
CNS- NFND
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What r the initial assesment?
DD?
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Immediate Assessment (<10 min)
Vital signs / O2 sat
IV Access
ABC
12 Lead ECG
Brief history
Fibrinolytic checklist
Physical examination
Cardiac marker levels
Electrolytes
Coagulation studies
CXR (EARLY)
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Describe your immediate
general treatment?
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Immediate General Treatment
OXYGEN
ASPIRIN
NITRATES
ONAM
MORPHINE
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Assess Initial 12-Lead
ECG
 Classify patients with acute ischemic chest
pain into 1 of 3 ECG classification groups:
STEMI
NSTEMI / UA
Nondiagnostic or Normal
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….ECG
• STEMI
ST elevation / presumed new LBBB 0.1mv or
1mm in 2 or more contiguous precordial leads or
2 or more adjacent limb leads.
•UA/NSTEMI
ST dep ≥ 0.5 mm (0.05mv) or dynamic T
inversions with pain or discomfort
Non-persistent or transient ST elevation
>0.5mm for less than 20 mins
•Nondiagnostic
ST deviation <0.5 mm or T inversions <0.2 mm
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“ J “ POINT
J point plus
0.04 second
PP baseline
ST-segment deviation
= 4.5 mm
The point at which the ST segment originates
from the QRS complex is called the J point
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ST-T Changes
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How to
identify LBBB
• Deep S wave in V1 and
a tall late R wave in
lead I and/or V6,wide QRS complexes
• WILLIAM
• Serial Cardiac markers for confirmation
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ECG diagnosis of LBBB
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AMI Localization
I lateral
aVR
V1 septal
V4 anterior
II inferior
aVL lateral
V2 septal
V5 lateral
III inferior
aVF inferior V3 anterior
V6 lateral
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INFERIOR WALL MI, RVMI
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Acute Inferior MI
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True Posterior MI
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CARDIAC MARKERS
• Limited role in case of diagnostic ST elevation in ECG
• Role in pts with nondiagnostic ECG changes
– Early diagnosis
– Missed MI
– Early risk stratification
Requires Serial Measurements rather than single (every 2-3
hours)
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…CARDIAC MARKERS
CK :
– Levels twice upper limit of
normal = abnormal
– Rises within 4-8hrs & falls
within 3-4 days
– False + results
CK-MB isoenzyme:
– More specific
– False +
AST : rise 18-36hrs post MI
LDH : rise 24-36hrs post MI
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…CARDIAC MARKERS
TROPONINS
 TnI more sensitive and specific in serial testing
& not at presentation.
 Starts to rise by 6 hrs & persists upto 7-10 days.
(diagnose late MI)
 Also elevated in myocarditis ,CM & pericarditis
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DIAGNOSTIC CRITERIA
(ANY TWO OUT OF THREE)
• Typical history
• ECG changes
• Cardiac enzyme elevation
CK
CKMB
TROPONIN
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Goals of treatment
• Door to needle time < 30 mins
(thrombolysis)
• Door to balloon time < 90 mins
(reperfusion)
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SCENARIO - 2
• A 40 year male, brought to ER with h/o sudden
onset chest pain & breathlessness since 2 hrs.
• Pleuritic pain, constant over the anterior thorax
• Has travelled from USA to INDIA 3 hrs back
• Chronic smoker
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VITALS
•
•
•
•
•
BP-100/60;
HR-146;
RR-42;
SPO2-88%
TROPONIN I – not
raised
•
•
•
•
CVS- tachycardia
RS – tachypnoea
PA – soft
CNS - NFND
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PULMONARY EMBOLISM
Pulmonary embolism (PE) is a blockage of the pulmonary artery or one of its
branches,
usually occuring when a venous thrombus becomes dislodged from its site of
formation and
embolizes to the arterial blood supply of one of the lungs.
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FACTS
• > 50 % pts with DVT are associated with PE
• > 50 % cases do not have any signs or symptoms
• Common presentation can be unexplained tachycardia,
tachypnoea, hypoxemia or mere anxiety
• Diagnosis and suspicion is purely clinical
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Clinical Features
Symptoms in Patients with Angio Proven
PTE
Symptom
Dyspnea
Chest Pain, pleuritic
Anxiety
Cough
Hemoptysis
Sweating
Chest Pain, nonpleuritic
Syncope
Percent
84
74
59
53
30
27
14
13
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Clinical Features
Signs with Angiographically Proven PE
Sign
Tachypnea > 20/min
Rales
Accentuated S2
Tachycardia >100/min
Fever > 37.8
Diaphoresis
S3 or S4 gallop
Thrombophebitis
Lower extremity edema
Percent
92
58
53
44
43
36
34
32
24
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ECG
–
Most Common Findings:
•
Tachycardia or nonspecific
ST/T-wave changes
–
Acute cor pulmonale or right
strain patterns
• Tall peaked T-waves in lead II
(P pulmonale)
• Right axis deviation
• RBBB
• S1-Q3-T3 (occurs in only 20%
of PE patients)
–
Atrial fibrillation / Atrial flutter
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Chest X ray
• Westermark’s sign
focal oligemia / cut off sign
• Hampton’s hump
peripheral wedge shaped density above the diaphragm
• Palla’s sign
enlarged right descending pulmonary artery
ALMOST ALWAYS NORMAL CHEST X-RAY
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WESTERMARK’S SIGN
HAMPTON’S HUMP
PALLA’S SIGN
ALMOST ALWAYS NORMAL
CHEST X-RAY
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Pulmonary Angiography
(GOLD STANDARD)
• Arrow indicates
abrupt
termination of a
pulmonary artery.
•
Www.brighamrad.Harvard.edu/case
s/bwh/images. A&E(VINAYAKA)
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RISK STRATIFICATION
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Heparin / LMWH / Warfarin
•
Heparin
80 U/kg iv bolus foll by 18 U/kg/hr
•
Enoxaparin
1 mg/kg twice daily / 1.5 mg/kg daily
•
Tinzaparin
175 mg/kg OD
•
Fondaparinux
<50 kg receive 5 mg,
50–100 kg patients receive 7.5 mg
>100 kg receive 10 mg.
•
Warfarin – 2.5 to 10 mg
Target INR – 2.0 TO 3.0
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THROMBOLYSIS
• Recombinant tPA
100 mg iv infusion over 2 hours
• Streptokinase
250,000 U iv over 30 mins foll by
100,000 U/hr for 24 hrs
• Urokinase
4,4OO U/kg iv over 10 mins foll by
4,000 U/kg/hr for 12 hrs
• Alteplase
15 mg iv bolus foll by 2 hr infusion of 85 mg
( discontinue heparin during infusion)
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EMBOLECTOMY
Indicated in pts with risk of
thrombolysis
• Surgical embolectomy
• Catheter embolectomy
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SCENARIO - 3
• A 30 year man brought to ER with h/o fall from a two
wheeler 10 mins back
• Severe chest pain, breathlessness since then.
• Chest pain & breathlessness increasing rapidly
• No external injuries
• No previous medical illness
• Occasional smoker
• What are your DD’s??????????
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IN ER
•
Sudden altered sensorium
•
Airway – patent
•
Breathing
RR- 47/min
Spo2 – 86 >>>>>>65%
shallow respirations
•
•
Absent breath sounds on rt
side
•
Tympanic note on percussion
•
Heart sounds heard- no
muffling
•
Engorged neck veins
Circulation
BP- 70/30 mmHg
HR- 156/ min
CBG- 126/ min
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TENSION
PNEUMOTHORAX
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Needle thoracocentesis
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Needle thoracocentesis
• Second intercostal space, midclavicular line on
the side of the tension pneumothorax.
• Upper border of lower rib
• Medially midclavicular line may damage the
great vessels, hilar structures and the heart.
• Under water seal- ICD IS A MUST.
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ICD IS A MUST
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DIAGNOSIS
•
•
•
•
•
Severe respiratory distress
Decreased breath sounds
Hyperresonance on percussion
Distended neck veins
Deviation of trachea to opposite side
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Tension pneumothorax
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SCENARIO - 4
•
A 54 year male brought to ER
with altered sensorium within
1 hour
•
Airway – patent
•
Breathing – shallow
RR- 40/min
Spo2- 78%
•
Circulation – BP-80/60
HR – 144/min
CBG – 144
•
GCS- 7/15
•
•
CVS – sinus tachycardia
RS – tachypnoea
crepitus over
mediastinum
•
PA – distension & rigidity
BS – not heard
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• k/c/o oesophageal stricture for which he
underwent an endoscopy
• Chronic alcoholic & smoker
• While awaiting his reports he devoloped acute
severe chest pain in 10 mins & sensorium
deteriorated in another 10 mins
• He was shifted to our hospital for further
management
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Diagnosis
• Chest X ray
• CT Chest
• Emergency endoscopy
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Rx
• ABC
• Fluid rescuscitation
• Broad spectrum parenteral
antibiotics
• Emergent surgical
consultation surgical
intervention
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SCENARIO - 5
• A 65 year old man comes to the ER with
h/o sudden onset of chest pain . He was
just about to go out for a meet with his
friends
• He is a K/C/O hypertension, DM for the
past 10 years on medications.
• He is a smoker
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•
•
•
•
•
•
•
•
He also c/o inability to move
his lower limbs now
Hoarseness of voice
Dysphagia
His femoral pulses are weak
when correlated with his
radial BP.
BP – 80/60
HR – 152
RR – 32
SPO2 – 88%
• CVS- tachycardia
• RS – inadequate chest
rise
• PA – soft , BS-sluggish
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AORTIC
DISSECTION
 Typical symptoms-Anterior chest pain,Neck or jaw
pain, Interscapular tearing or ripping pain ,
 Reduced perfusion- Myocardial infarction
,Neurologic symptoms, Syncope, Stroke symptoms
,Altered mental status, Hemiparesis or hemiplegia
 Symptoms of compression- Horner syndrome,
Dyspnoea, Dysphagia ,Orthopnoea, Flank pain, and
hemoptysis
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Investigations
• Angiography is gold standard
• Aortography-dissection in branch vessels,AV
incompetence
• Contrast problems and arranging the team
• USG Thorax/ TEE
• CT –fast with IV contrast.
preferred in unstable
• No details of branches
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• TEE in experienced
hands-useful.
• CXray-thoracic Aortawidening of
mediastinum, abnormal
aortic contour, Pl Eff,
tracheal deviation,
• Intimal calcium sign.
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Management
 Reduce BP-shearing force- negative inotrope
 Beta blocker- esmolol, metaprolol
 Esmolol 500 mic/kg bolus
maint 50-100 mics/kg/min
 Vasodilator-SNP- 0.3 mic/kg/min IV
 Immediate surgical referral
 Surgical exploration
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TAKE HOME MESSAGE
 Prompt aggressive control of ABC saves > 50% of cases
 Atypical presentations are common
 Chances of missed diagnosis is high
 Approach every chest pain as a life threatening disorder
 Serial monitoring is required
 GERD is a diagnosis of exclusion
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References

Circulation 2005

ACLS Provider 2006

Textbook of emergency medicine; Judith.E.Tintinalli

Harrison’s principles of Internal Medicine;17th Edition

Braunwald’s

Critical Care Book by Edward & Fink

Rosen’s etxt book of emergency medicine

ACC and AHA Guidelines 2006.

Oxford hand book of cardiology.

E-Medicine
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