Chest Pain

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Case I Josh is 53 year old male who presents to the emergency department at midnight. He has developed some chest pain over the last couple of hours. When it did not resolve with tums he became worried prompting this visit. He drove here alone and walked in without difficulty. What is your initial assessment and intervention? John is not ill appearing, but is notably anxious. His respiratory rate is 18 and unlabored. His pulse is 60 and regular. His blood pressure is 110/68 and SPO2 is 98%. Supplementary O2 is available if he desaturates. He has an 18 angiocath in the right anticubital space. What are the 5 life-threatening causes of chest pain? How do their classic presentations differ? How common are their classic presentations?

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What is your next step in assessment? John developed this chest pain at rest. It is felt as pressure and aching over the epigastrium and left side of his chest. He is anxious and diaphoretic. He is nauseated without vomiting. He has had similar episodes of pain, but usually with heavy exertion. He has not been evaluated for the m yet. His ROS is otherwise negative. He is currently being medicated for hyperlipidemia and hypertension. He has no significant surgical history. He smokes 1 ppd and drinks 2-3 beers daily.

What are classic ACS risks? How important are they to determine? What is your next step in assessment and testing?

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What is your interpretation of the patients ECG on the previous page?

What treatments are typically given in the setting of an MI? What benefits do they provide?

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What precautions should be taken with possible right sided myocardial infarcts? John is found to have an inferior myocardial infarction. In triage he is given 4 baby aspirins. He is given morphine to help control pain, but is not given nitro due to soft blood pressures. He is give 3 500ml saline boluses. The interventional cardiology team is consulted and is on their way down to evaluate and prepare him for the cath lab. In the meantime Plavix 600mg is given and a heparin drip is started. Cardiology advises to hold off on GIIb/IIIa agents until they evaluate.

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Case II Jane is 43 year old female with a history of hypertension, hyperlipidemia, coronary artery disease, and diabetes who presents with chest pain over the last hour. What is your initial assessment and intervention? Jane is nontoxic, but looks uncomfortable and has labored breathing. Her respiratory rate is 22. Her pulse is 106 and regular. Her blood pressure is 136/86 and SPO2 is 96%. Given her labored breathing, she is started on O2 by nasal cannula at 2L/min. IV access is attained and an ECG was ordered by triage. What is your next step in assessment? Jane has had this pain over the last hour which began at rest. She describes it as pleuric in nature, which makes the accompanying cough particularly uncomfortable. She has some shortness of breath that is worsened by exertion. She has had some lower extremity pain over the last week, but attributes it to a musculoskeletal injury sustained 2 weeks ago. She has not had a similar event in the past. Her ROS is otherwise negative. She is currently taking estrogen/progesterone contraceptives for menorrhagia and is being followed closely by her gynecologist. She takes HCTZ, Lipitor, and metformin. She has no significant surgical history. She smokes 1/2 ppd and drinks an occasional glass of wine.

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What are some of the non-life threatening causes of chest pain? What are your differential diagnosis and your chief concerns for Jane at this point? Jane vitals are unchanged at the time of her physical exam. She has diffuse wheezing over the right hemithorax. She has bruising of the right ankle at the site of her prior injury, with swelling and tenderness ascending up the calf. What are the major risk factors for primary diagnosis? What is the significance of attaining these? What is her probability of having a PE? How does this probability change your diagnostic testing?

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What are the most common findings on ECG or CXR in patients with a pulmonary embolism?

What are treatment options for minor and major PEs? What would you use in Janes situation?

Jane had standard chest pain labs drawn and were within normal limits. He ECG showed tachycardia and nonspecific T wave changes. A bedside ultrasound of the right leg was consistant with DVT. She was promptly started of heparin prior to imaging. The CT-PA was performed and confirmed the diagnosis. She was admitted to the step down unit for further monitoring.

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Case III Greg is a 67 year old male with sudden onset of chest pain. The pain started in the hospital parking lot as he was on his way to see his cardiologist. He is escorted in a wheelchair by security to the emergency department. What is your initial assessment and intervention? Greg is diaphoretic, pale, and anxious. He has a low grade fever. His respiratory rate is 20. His pulse is 88 and regular. His blood pressure is 110/54. A nonrebreather is placed on him with O2 at 15L/min. IV access is attained. A technician is performing an ECG. What is your next step in assessment? Greg began felling left sided chest pain on arrival to the hospital. It is somewhat pleuritic in nature. He was recently hospitalized for a STEMI 2 weeks ago.

Describe different types of post-infarction complications exist? How and when to they present?

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What is the most likely cause of Gregs current presentation? What work up would you do at this time? Gregs physical exam is within normal limits. He has basic labs drawn. His ECG reveals diffuse ST elevations. A bedside ultrasound shows mild pericardial thickening and a pericardial effusion. He is admitted for monitoring and treated with NSAIDs and steroids.