chest pain on the acute medical take acute block uhcw september 25 th 2014
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Chest Pain On The Acute Medical Take
Acute Block UHCWSeptember 25th 2014
Dr. Adam IqbalClinical Teaching Fellow
UHCW NHS Trust
ObjectivesBy the end of this session you should be able to:
• List the common and serious causes of chest pain presenting to the acute medical take
• Recognise the clinical features of (interactive discussion):
– Acute coronary syndrome, aortic dissection, pericarditis
– Pulmonary embolism, pneumothorax
– Exacerbation of COPD & acute asthma
• Recognise radiological features of:
– Pericardial effusion
– Pneumothorax
– Pulmonary embolism
• Discuss management of acute coronary syndromes (didactic teaching)
Clinical Assessment
A
B
C
D
E
1. IDENTIFY problem
2. CORRECT abnormalities
…then PROCEED
• History:
– SQITAS
– Problem solving
– PMHx
– DA
– SHx, FHx
Which system?
Cardiac
Respiratory Musculoskeletal
Gastrointestinal Neurological
Clinical Features of ACS …HISTORY CLINICAL EXAMINATION
Clinical Features of ACS …HISTORY
Sudden onset central chest pain
“Squeezing, tight, crushing, pressure, dull ache”
Radiation – neck, jaw, arms
Typically severe (subjective!)
Precipitated by exertion, relieved by rest (but beware unstable disease)
Sweaty, nauseous, collapse
DM, smoker, IHD, male, age, FHx, alcohol, HTN, PVD, renal failure
(Beware atypical presentation in women, DM, elderly)
CLINICAL EXAMINATION
Usually normal unless complications
May be some evidence of risk factors: PVD (i.e. bypasses, tissue loss), DM (fingerprick), tar staining, hypertensive changes (retinal, bruits), arcus
Clinical Features of Aortic Dissection
HISTORY CLINICAL EXAMINATION
Clinical Features of Aortic Dissection
HISTORY
Sudden onset severe central chest pain
“Tearing”
Radiation – arms, back
May ‘migrate’
Neurological symptoms
Autoimmune rheumatic disorders, Ehlers-Danlos, Marfan’s, HTN, trauma, recent instrumentation of aorta
CLINICAL EXAMINATION
Tachycardic, raised BP
Brachial pulse discrepancy
Proximal extension:
murmur (AR), cardiac tamponade/ischaemia
Distal extension:
renal failure, visceral, limb, or spinal ischaemia
Clinical Features of Pericarditis
HISTORY CLINICAL EXAMINATION
Clinical Features of Pericarditis
HISTORY
Sharp central chest pain
Worsened by movement, breathing, and lying down (relieved by sitting forwards)
Hx of recent cardiothoracic insult (surgery, radiotx, trauma) or MI (AMI, Dressler’s)
Recent viral, bacterial, tuberculous illness
CLINICAL EXAMINATION
Pericardial rub
Features of pericardial effusion
Haemodynamic compromise
Features of acute heart failure (myocarditis or constrictive pericarditis)
Clinical Features of Pulmonary Embolism
HISTORY CLINICAL EXAMINATION
PEs can be small, massive, or multiple
Clinical Features of Pulmonary Embolism
HISTORY
Dyspnoea (chronic or sudden onset)
Chest pain (+/- pleuritic)
Cough (+/- haemoptysis)
Risk factors: prev VTE, smoker, pregnancy, immobility, recent surgery, dehydrated, FHx VTE, drugs, OCP
CLINICAL EXAMINATION
Tachypnoea, tachycardia
Raised JVP, hypotension
Features of pulm HTN
Minimal chest signs
Peripheral DVT
PEs can be small, massive, or multiple
Clinical Features of Pneumothorax
HISTORY CLINICAL EXAMINATION
Clinical Features of Pneumothorax
HISTORY
Sudden onset unilateral pleuritic chest pain or progressively increasing breathlessness
Cough
Young male (M:F ratio 6:1), tall, COPD, asthma, ca lung, suppurative lung disease, instrumentation (!!)
CLINICAL EXAMINATION
Tachypnoea, desaturation
Haemodynamic compromise if tension
Reduced expansion, tympanic PN
Mediastinal shift
Clinical Features of COPD Exacerbation
HISTORY CLINICAL EXAMINATION
Clinical Features of COPD Exacerbation
HISTORY
Cough, Phlegm, Fever
Chest pain (tightness, sharp/pleuritic)
SOB, wheeze
Smoker, known obstructive spirometry, under resp physician, frequent exacerbations
CLINICAL EXAMINATION
Tar staining, CO2 flap, tachypnoea, tachycardia, cyanosis, hyperexpanded chest, accessory muscle use, resonant PN, crackles, bronchial sounds, wheeze, prolonged expiratory phase
Clinical Features of Acute Asthma
HISTORY CLINICAL EXAMINATION
Clinical Features of Acute Asthma
HISTORY
SOB
Cough
Wheeze
Phlegm
(Diurnal variation, triggers)
Hx of atopy
DA: beta-blockers, NSAIDs
CLINICAL EXAMINATION
Tachypnoea, tachycardia
Widespread wheeze
Accessory muscle use
Desaturation, cyanosis, see-sawing
Acute Coronary Syndrome
• Make the diagnosis !
• Manage cause / condition / complications
ACS
Angina UA NSTEMI STEMI
Pathophysiology
Angina Unstable Angina
• Exertional
• Relieved by rest
• ± ECG changes ( ST depression, T wave inversion)
• Troponin negative
• Can occur at rest
• Crescendo
• ± ECG changes ( ST depression, T wave inversion)
• Troponin negative
NSTEMI STEMI
• Troponin +ve
• ± ECG changes (ST depression/ T wave inversion)
• Troponin +ve
• ST elevation
– 2mm in 2 consecutive chest leads
– 1mm in 2 limb leads
• New onset LBBB
Acute Management of ACS• A-E assessment (ECG vital)• Identify Problem > Correct > Reassess > Proceed• Monitoring (!!)• UA / NSTEMI
– Aspirin 300mg, Clopidogrel 300mg, Clexane 1mg/kg SC BD• STEMI
– 2222 (!!)– Aspirin 300mg, Ticagrelor 180mg
• Manage symptoms / complications– Beta-blockers prevent arrhythmias (!!)– GTN (SL or infusion)– Analgesia (diamorphine 2.5-10mg IV) & Antiemetic (metoclopramide
10mg IV)– Careful clinical assessment (arrhythmias, heart failure, RVF etc)– Oxygen ONLY IF HYPOXIC
ABSOLUTE CONTRAINDICATIONS
•Active bleeding or GI bleed < 4/52
•Suspected aortic dissection
•Surgery/Trauma/Head injury < 2/52
•Recent non-embolic stroke <6/12
RELATIVE CONTRAINDICATIONS
•HTN
•Prolonged CPR (>5min)
•Pregnancy
•Therapeutic anticoagulation
•Retinopathy
Investigations• Electrocardiogram – serial
• Blood tests– Full Blood Count / U&E
– Lipid Profile / BMs
– Clotting screen
– Troponin (in this trust 3hrs & 6hrs)
• Chest radiograph
• Echocardiogram (LV function)
• Coronary angiogram > PCI
• Myocardial perfusion scan
Post Event management• Lifestyle & risk factor modification
– Smoking cessation– Dietary changes– Exercise– Diabetes & dyslipidaemia– HTN
• Secondary prevention– ACE-I– Beta-Blocker– Statins– Dual anti-platelet therapy for 1yr, aspirin for life
• Cardiac rehabilitation• Clinic follow up & repeat echocardiography
Summary
• Chest pain is the single most common presenting complaint on the acute take
• Know how to recognise the serious (& rare!)
• Reassure the patient
• Bear in mind causes not discussed here i.e. GI
• Apply your clinical reasoning (as opposed to questioning by rote) & you will recognise what you have never seen
• Be thorough, systematic, logical and … keep an open mind!
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