Chest Pain: An Approach Raja Dhar

Transcription

1 Chest Pain: An Approach Raja Dhar MD, MRCP (UK), MSc (EBM, UK), CCT (UK), FCCP (US) Consultant Respiratory Physician, Fortis Director, Education and Research NAABI Kolkata.

2 The background: Chest pain is one of the most common chief complaints of patients presenting to EDs annually. 8-10% of the 119 million annual ED visits are for chest pain and related symptoms Accurate diagnosis remains a challenge

3 CHEST PAIN there are a lot of importment data of the pain: localisation radiation onset of the pain the type (press, smart,cutting) dinamic of the pain (continouosly, ongoing, undulaiting) answer to the medical therapy

4 Chest Pain Visceral Often referred Aching, heaviness, discomfort Difficult to localize pain Somatic Sharp, easily localized

5 Categorizing Chest Pain 1. Chest Wall Pain Sharp, Precisely localized Reproducible: Palpation, movement 2. Pleuritic or Respiratory CP Somatic pain, Sharp Worse with breathing/coughing 3. Visceral CP Poorly localized, aching, heaviness

6 1. Chest wall Costosternal synd Costochrondritis Precordial catch synd Slipping Rib Synd Xiphodynia Radicular Synd Intercostal Nerve Fibromyalgia 2. Pleuritic Pulmonary Embolism Pneumonia Spontaneous pneumo Pericarditis Pleurisy

7 3. Visceral Pain: Typical Exertional Angina Atypical Angina Unstable Angina Acute Myocardial Infarction (AMI) Aortic Dissection Pericarditis Esophageal Reflux or spasm Esophageal Rupture Mitral Valve Prolapse

8 Common benign causes of chest pain?

9 Benign Causes Musculoskeletal Esophagitis Bronchitis (Chest Pain secondary to cough) Recently placed nipple rings Non-Specific Chest Pain * *Most common means we don t know, but it is not going to hurt you.

10 What are the 6 causes of chest pain that can kill?

11 What are the key parts of the History in the CP patient? What can you get out of the pt in 4 minutes?

12 History matters! Location: Central, left, or right Associated symptoms: SOB, sweating, nausea Timing: Gradual or sudden onset Provocation: What makes worse or better? Quality: Visceral vs somatic Radiation: Back, neck, arm Severity: Scale of 1-10

13 What are the key parts of the rest of the History? What can you get out of the pt in 4 minutes?

14 The Rest of the History PMH Duh Meds Cardiac meds? Nitro? ASA? Clopidogrel? Coumadin? Allergies Always important! Social Smoker? Alcoholic? Cocaine? Family Sudden Death? Early MI? DVT? PE?

15 What are the key parts of the Physical? What can you exam in only 2 minutes?

16 Key Emergency Physical General Appearance Vital Signs Heart (Muffled? Regular? Fast?) Lungs (Equal? Wet? Tympanitic?) Neck (JVP?) Abdomen (Distention?) LE (Edema? calf tenderness?)

17 This guy is rushed back by EMS, what do you do?

18 Approach to Chest Pain INITIAL GOAL in ED is to identify life threats MI, PE, aortic dissection Remember ABCs always first

19 What do you do in the first 60 seconds?

20 First 60 seconds How does the pt look? What are the pt s vital signs? EMS story?

21 Next 5 minutes? What are 2 bedside tests to consider? What is an important and cheap medication you should consider?

22 Next 5 Minutes Brief History. Brief Physical (ABCs) What are 2 bedside tests that can be done to help stratify the pt? ECG Portable CXR What is an important and cheap medication you should consider? ASA (More on this later from Dr Roy)

23 Next 10 Minutes Patient already stabilized, initial data gathered, and initial orders submitted Secondary survey: More detailed history and physical exam Address patient s pain Goal now is to categorize patient 1) Chest wall pain- Musculoskeletal 2) Pleuritic chest pain- Respiratory 3) Visceral chest pain- Cardiac

24 Differential Diagnosis of Chest Pain Non Cardiac Cardiac

25 Non Cardiac Chest Pain Pulmonary Musculoskeletal Pneumonia Costochondritis Pleuritis Cervical Disk Disease Pneumothorax Rib Fracture Pulmonary Embolism Intercostal Muscle Cramp Tumor Other Gastrointestinal Herpes Zoster GERD Disorders of the Breast Esophageal spasm Splenic Infarct Mallory-Weiss Tear Panic Attacks/Anxiety Disorder Peptic Ulcer disease Fibromyalgia Biliary/Gallbladder Disease DKA Pancreatitis

26 Cardiac Chest Pain Aortic Dissection Acute Coronary Syndromes Pulmonary Embolism Stable Angina Pulmonary Hypertension Unstable Angina Pericardial Diseases Myocardial Infarction Aortic Stenosis Cardiogenic Shock Heart Failure Cocaine Abuse

27 PE Non Cardiac PTX Oesophageal disaster Chest Pain Coronary spasm Aortic disease Cardiac Myo/pericardium Obstructive CAD Stable angina Coronary disease ACS

28 Pulmonary Embolism:

29 PE: Presentation Presentation variable Suspect in any patient c/o new or worsening dyspnoea, chest pain or prolonged hypotension without obvious etiology Symptoms: dyspnoea (sec. to min) > pleuritic chest pain > cough Signs: tachypnoea > tachycardia > rales > loud P2

30 PE: Diagnosis

31 PE: Management

32 PE: Clinical guidelines

33 PE: Anticoagulation Enoxaparin 1mg/kg Q12H UFH: 80IU/kg then 18IU/hr (5000IU max) Fondaparinux 5mg daily if <50kg 7.5mg daily if kg 10mg daily if >100kg If clinical suspicion high, initiate anticoagulation prior to confirming diagnosis

34 Long term management: V-K antagonists LMWH preferred in patients with malignancy or pregnancy Duration: 1 st provoked: 3mo 1 st unprovoked, malignancy or recurrent, consider indefinite tx

35 PE Non Cardiac PTX Oesophageal disaster Chest Pain Coronary spasm Aortic disease Cardiac Myo/pericardium Obstructive CAD Stable angina Coronary disease ACS

36 Pneumothorax: Presentation Primary Spontaneous PTX: Seen in patients without underlying lung disease Smoking, FH and Marfans predispose Usually 20s-40s, present with sudden onset dyspnea and pleuritic CP at rest Physical findings include decreased chest excursion, decreased breath sounds, hyperresonance Hypoxeima common, hypercapnea uncommon 2/2 perfusion of PTX but adequate ventilation with contralateral lung

37 Pneumothorax: Presentation Secondary Spontaneous PTX Seen in patients with underlying lung disease Any lung disease predisposes however COPD most common PCP, CF and TB also common causes Similar physical presentation to PSP ABG typically abnormal 2/2 underlying lung disease

38 Pneumothorax: Diagnosis CXR: Look for pleural line Can be difficult in patients with COPD CT scan can overestimate size of PTX

39 Pneumothorax

40 Pneumothorax

41 Pneumothorax: Treatment ABCD Assess haemodynamic stability If < 2cm and stable, can observe If > 2cm, chest tube If haemodynamically unstable, chest tube

42 PE Non Cardiac PTX Oesophageal disaster Chest Pain Coronary spasm Aortic disease Cardiac Myo/pericardium Obstructive CAD Stable angina Coronary disease ACS

43 Oesophageal rupture: Hospitalized: >50% 2/2 instrumentation of esophagus Traumatic: MVA, chest wall trauma Spontaneous: (transmural perforation) Vomiting (Boerhaave s Syndrome): retching followed by severe chest and epigastric pain, tachypnoea, dyspnoea, fever, cyanosis, shock Caustic ingestion, pill esophagitis, Barrett s, oesophageal ulcers in HIV patients

44 Oesophageal rupture: Diagnosis CXR: early shows mediastinal or free peritoneal air Hours to days later: widening of mediastinum, pleural effusion

45 Oesophageal rupture: CT scan: Oesophageal oedema, extra oesophageal air, perioesophageal fluid Oesophagram: Extravasation of contrast NO role for endoscopy which introduces more air into mediastinum

46 Oesophageal rupture: Treatment Management variable and depends on size, location, rapidity of diagnosis and underlying disease Treatment surgical Complications: mediastinitis, sepsis, shock, death

47 PE Non Cardiac PTX Oesophageal disaster Chest Pain Coronary spasm Aortic disease Cardiac Myo/pericardium Obstructive CAD Stable angina Coronary disease ACS

48 Aortic dissection: Presentation Sharp, tearing anterior or posterior chest and back pain. Typically sudden onset and severe Chest pain more common with type A dissections Complicated by CVA, syncope, MI (RCA) or HF

49 Aortic dissection: Diagnosis Generally suspected by history/physical Variations in pulses or blood pressure (>20 mmhg difference between R and L arm) ECG: variable depending on complications Imaging when stable CXR: mediastinal widening CT chest, TEE, MRI other options and all superior to TTE

50 Aortic Dissection: Predisposing factors: Aortic aneurysm HTN Vasculitis Marfan s or other collagen diseases CABG/cardiac catheterizaion Drugs (crack cocaine) Trauma

51 Aortic dissection: Classification

52 Aortic dissection

53 Aortic dissection

54 Aortic Dissection: Management Type A: Surgical Type B and uncomplicated: Medical Type B and complicated (major branch involved, continued expansion or aortic rupture Long term management includes B blocker, serial imaging at 3, 6 and 12 months and reoperation if indicated

55 Acute Management ICU admission Pain control: Morphine Reduction of SBP to or lowest tolerated, HR <60, intubate if unstable IV B blocker 1 st line (labetolol, propranolol, esmolol) If HR <60 and SBP >100 with good mentation and renal function nitroprusside If hypotensive, look for blood loss, tamponade or HF prior to giving volume

56 PE Non Cardiac PTX Oesophageal disaster Chest Pain Coronary spasm Aortic disease Cardiac Myo/pericardium Obstructive CAD Stable angina Coronary disease ACS

57 Pericarditis Chest pain (anterior chest, sharp, pleuritic, exacerbated by inspiration, can decrease with leaning forward, radiation to trapezius) Often first sign of other systemic disease Multiple possible etiologies, viral and autoimmune most common in US Consider TB outside US

58 Pericarditis: ECG:

59 Pericarditis: Treatment NSAIDs are mainstay of therapy (IBU or high dose ASA Can also use colchicine or glucocorticoids Tamponade: conservative management with monitoring, serial echo, volume expansion and treatment of underlying cause vs. pericardiocentesis

60 PE Non Cardiac PTX Oesophageal disaster Chest Pain Coronary spasm Aortic disease Cardiac Myo/pericardium Obstructive CAD Stable angina Coronary disease ACS

61 What is in store? The E module I will look at each aspect of the Non Cardiac causes of Chest Pain An approach to the differential How we would approach and treat each of these cases individually when you encounter them in your day to day practice. What you should do and where to seek help