APPROACH TO CHEST PAIN

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. BACKGROUND.

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APPROACH TO CHEST PAIN

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  1. 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
  2. BACKGROUND • Approx 5% of all ED visits • 15% - AMI • 25-30% - Unstable angina • 14 -34% - Other conditions • Atypical presentations – common
  3. ACUTE CHEST PAIN • Recent onset, typically less than 24 h • Location described on the anterior thorax • A noxious uncomfortable sensation distressing to the patient.
  4. CATEGORISATION • Visceral pain • Pleuritic pain • Chest wall pain
  5. Typical exertional angina Atypical angina Unstable angina Acute myocardial infarction Aortic dissection Pericarditis Oesophageal reflux or spasm Oesophageal rupture Mitral valve prolapse VISCERAL PAIN
  6. Pulmonary embolism Pneumonia Spontaneous pneumothorax Pericarditis Pleurisy PLEURITIC PAIN
  7. Costosternal syndrome Costochondritis Precordial catch syndrome Slipping rib syndrome Xiphodynia Radicular syndromes Intercostal nerve syndromes Fibromyalgia CHEST WALL PAIN
  8. Etiology Etiology Etiology Etiology Etiology Etiology Etiology Etiology Etiology Etiology Etiology Etiology Etiology Etiology Etiology Etiology Etiology Etiology Etiology Etiology Etiology Etiology Etiology Etiology Etiology Etiology Etiology Etiology Etiology Etiology Quality Quality Quality Quality Quality Quality Quality Quality Quality Quality Quality Quality Quality Quality Quality Quality Quality Quality Quality Quality Quality Quality Quality Quality Quality Quality Quality Quality Quality Quality Location Location Location Location Location Location Location Location Location Location Location Location Location Location Location Location Location Location Location Location Location Location Location Location Location Location Location Location Location Location Radiation Radiation Radiation Radiation Radiation Radiation Radiation Radiation Radiation Radiation Radiation Radiation Radiation Radiation Radiation Radiation Radiation Radiation Radiation Radiation Radiation Radiation Radiation Radiation Radiation Radiation Radiation Radiation Radiation Radiation Duration Duration Duration Duration Duration Duration Duration Duration Duration Duration Duration Duration Duration Duration Duration Duration Duration Duration Duration Duration Duration Duration Duration Duration Duration Duration Duration Duration Duration Duration Asso.Symptoms Asso.Symptoms Asso.Symptoms Asso.Symptoms Asso.Symptoms Asso.Symptoms Asso.Symptoms Asso.Symptoms Asso.Symptoms Asso.Symptoms Asso.Symptoms Asso.Symptoms Asso.Symptoms Asso.Symptoms Asso.Symptoms Asso.Symptoms Asso.Symptoms Asso.Symptoms Asso.Symptoms Asso.Symptoms Asso.Symptoms Asso.Symptoms Asso.Symptoms Asso.Symptoms Asso.Symptoms Asso. Symptoms Asso.Symptoms Asso.Symptoms Asso.Symptoms Asso.Symptoms Onset Onset Onset Onset Onset Onset Onset Onset Onset Onset Onset Onset Onset Onset Onset Onset Onset Onset Onset Onset Onset Onset Onset Onset Onset Onset Onset Onset Onset Onset MI MI MI MI MI MI MI MI MI MI MI MI MI MI MI MI MI MI MI MI MI MI MI MI MI MI MI MI MI MI visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm Neck jaw shoulder arm >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min >15 min Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea Nausea, vomiting, diaphoresis, dyspnoea variable variable variable variable variable variable variable variable variable variable variable variable variable variable variable variable variable variable variable variable variable variable variable variable variable variable variable variable variable variable angina angina angina angina angina angina angina angina angina angina angina angina angina angina angina angina angina angina angina angina angina angina angina angina angina Angina angina angina angina angina visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral visceral retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal retrosternal Neck, Jaw shoulder, arm Neck, Jaw shoulder, arm Neck, Jaw shoulder, arm Neck, Jaw shoulder, arm Neck, Jaw shoulder, arm Neck, Jaw shoulder, arm Neck, Jaw shoulder, arm Neck, Jaw shoulder, arm Neck, Jaw shoulder, arm Neck, Jaw shoulder, arm Neck, Jaw shoulder, arm Neck, Jaw shoulder, arm Neck, Jaw shoulder, arm Neck, Jaw shoulder, arm Neck, Jaw shoulder, arm Neck, Jaw shoulder, arm Neck, Jaw shoulder, arm Neck, Jaw shoulder, arm Neck, Jaw shoulder, arm Neck, Jaw shoulder, arm Neck, Jaw shoulder, arm Neck, Jaw shoulder, arm Neck, Jaw shoulder, arm Neck, Jaw shoulder, arm Neck, Jaw shoulder, arm Neck, Jaw shoulder, arm Neck, Jaw shoulder, arm Neck, Jaw shoulder, arm Neck, Jaw shoulder, arm Neck, Jaw shoulder, arm
  9. Etiology Quality Location Radiation Duration Asso. Symptoms Onset Aortic dissection severe retrosternal Inter scapular tearing constant Nausea diaphoresis, dyspnoea Sudden PE pleuritic lateral constant dyspnoea sudden Pneumothorax pleuritic lateral Neck, back constant dyspnoea sudden
  10. 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.
  11. BP-110/60 HR-104 RR-34 SPO2-95% CVS – Tachycardia RS - Tachypnoea PA - Soft CNS- NFND VITALS
  12. What r the initial assesment?DD?
  13. Immediate Assessment ( Cardiac marker levels Electrolytes Coagulation studies Vital signs / O2 sat IV Access ABC Brief history Fibrinolytic checklist Physical examination 12 Lead ECG CXR (EARLY)
  14. Describe your immediate general treatment?
  15. Immediate General Treatment ONAM OXYGEN NITRATES MORPHINE ASPIRIN
  16. Assess Initial 12-Lead ECG • Classify patients with acute ischemic chest paininto 1 of 3 ECG classification groups: • STEMI • NSTEMI / UA • Nondiagnostic or Normal
  17. ….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
  18. “ J “ POINT J point plus 0.04 second ST-segment deviation= 4.5 mm PP baseline The point at which the ST segment originates from the QRS complex is called the J point
  19. ST-T Changes
  20. 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
  21. ECG diagnosis of LBBB
  22. AMI Localization I lateral aVR V1 septal V4 anterior II inferior aVL lateral V2 septal V5 lateral V6 lateral III inferior aVF inferior V3 anterior
  23. INFERIOR WALL MI, RVMI
  24. Acute Inferior MI

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