Acute Chest Pain
Dr.S.R.Pahlavanpoor
EMS Chief Manager
Perspective&Epidemiolgy
.More than 5 milion patient to the ED each year
with complaints of chest pain;this represents
nearly 5% of all patients seen in the ED in the
US.
Perspective&Epidemiolgy
.Critical Dx causing chest pain:
.ACS:most significant potential Dx in the ED
.Aortic dissection
.Pulmonary embolus
.Pneumothorax
.Pericarditis with tamponad
.Esophageal rupture
1-Rapid assessment and stabilization
A-all patients except those with obvious benign
cause of CP are transported as promptly as
possible to the treatment area
B-cardiac manitor- oxygen therapy-IV line-and
assessing patients appearance and V/S
C-if the patient shows sign&symptoms of Tension
Pneumothorax(CP-RD-Shock-Unilateral reduction
or absence of breath sound)need to immediate
intervention(needle/tube thoracostomy)
1-Rapid assessment and stabilization
D- Check V/S:
.if V/S derangement and patient symptomatic:
TREATED as APPROPRIATE
.if V/S are stable brief Hx and P/E are performed
E-ECG-CXR
ECG performed in all patients with CP includes all
patients 30 Yr old and older
CXR performed for patients with serious cause of CP
1-Rapid assessment and stabilization
F- Laboratory test
G- Confirm of Dx & Treatment
ACS(acute coronary syndrom)
Spectrum of clinical presentation result from
common pathophysiology of Myocardial
ischemia and Necrosis
Include from asymptomatic CADand STABLE
ANGINA to UNSTABLE ANGINA and AMI and
SUDDEN CARDIAC DEATH.
STABLE ANGINA
TRANSIENT Episode of CP or Discomfort that
typically reproducible with frequency of attack
constant over time.
1- Classical Hx:
a:character:pain or discomfort with ;pressure ;or
heaviness; sensation
b:location:substernal or precordial radiate to
neck-jaw-arm
STABLE ANGINA
Location and radiation typically in left side of
chest but sensate in both side or only in right
side.
c:duration:last from 2-5 minutes up to 20
minutes
d:exacerbation with exertion-heavy meal-stresscold
Alleviation by rest
Angina Equivalent Symptom
Arise alone(Atypical Hx) or in combination with
angina and include:
Dyspnea-nausea-vomiting-diaphoresisweakness-dizziness-excessive fatigue-anexiety
.compliant of GASand INDIGESTION or
HEARTBURN in the absence of known Gereflux
or Reproducible pain upon abdominal
palpation should rise suspicion of ACS
STABLE ANGINA
2- Atypical Hx:
a: atypical features in character(pluriticpositional-reproducible by palpation)duration-location and exacerbating factor
b: presence of AES alone
c: common seen in DM-Older age-Female
gender-Dementia ……
STABLE ANGINA
d: in older age(>85Yr):
Stroke-weakness-AMS-are more common than CP.
e:in patient with DM:
Atypically sympton are common(dyspnea-nausea
and vomiting-cofusion- fatigue)
f:in Female gender:high risk of AMI without CP
Common symptom:dyspnea-indigestion-weaknessunusual fatigue-cold sweat-sleep disturbanceanexiety-dizziness
UNSTABLE ANGINA
New – onset angina
Angina at rest or occurring with minimal
exertion
Worsening change in previously STABLE ANGINA
(in frequency or duration of attack or resistance
to previously effective medication)
VARIANT ANGINA
Caused by coronary artery vasospasm at rest
and it may be relieved by exercise or NTG
AMI:
Includ combination of Clinical symptom-ECG
change-tupically rise and fall in CK-MB and
TROPONIN
Aortic Dissection
Rapid onset+sever CP
Maximal at beginning
Radiate anteriorly in chest to the back
interscapular area or into the abdomen
Pain often has a TEARING
Neurologic complication of stroke-peripheral
neuropathy-paresis or paraplegia-abdominal
and extremity ischemia
PULMONARY EMBOLISM
Pain often lateral-pleuritic
Centerl pain:massive embolus
Abrupt in onset and maximal at beginning
May be episodic or intermittent
Dyspnea(prominent role)
Cough-Hemoptysis(,20%)
Angina like pain(5%)
ESOPHEGEAL RUPTURE
Pain usually preceded by vomiting
Abrupt onset
Pain is persistent and unrelieved
Localized along the esophagus
Increased by swallowing and neck flexion
Diaphoresis-dyspnea-shock
PNEUMOTHORAX
Pain uaually acute and abrupt onset
Often lateral-pleuritic
Central in largs pneumothorax
Dyspnea-AMS-Shock
PERICARDITIS
Dull and recurrent pain unrelated to exercise or
meal
Sharp or pleuritic
Not relieve by NTG
Dyspnea-diaphoresis
ECG in CP
ECG performed in all patients with CP includes
all patients 30 Yr old and older
In ACS:ST segment change(STdep:./5mmSTele:./6-1mmor.1mm-Twave inversion>1mm(
New LBBB
Seen normal or nonspecific ECG in pateints with
ACS
Diffuse ST ele in Pericarditis
CXR in CP
Wide mediastinum in Acute Aortic Dissection
Mediastinal Air Fluid level or
Pneumomediastinum in Esophageal Rupture
LAB test in CP
Serum D dimer may help discriminate patients with
Pulmonary Embolus
CK-MB and Troponin(IandT) when elevated identify
with ACS who have the highest risk for
complication.
Asignificant increase (2-3 time from baseline)has
been shown to be more sensitive than isolated
measurements ofany enzyme
Single value of any enzyme can not be used to
exclude ACS as a cause of pain
TREATMENT
If cardiac cause is suspected and V/S is stabled
pain relief with NTG(./4mg SL every 3-5
minutes for 3 dose+ Aspirin(81-325mg)is given
and in patients with contraindication to
Aspirin CLOPIDOGREL(loading dose 300mg) is
given.
PERICARDIAL TAMPONADE
Patient with low volage in ECG-diffuse ST eleelevated jvp-and sign of shock:
Confirm Dx by echo cardiography and treated
by Pericardiocentesis.
THE END
THANKS