Chest Pain

(Non - Trauma)
Oleh : M. Samsul Arifin 0810710072 Nur Hidayati Azar 0810710088 Peppy Tria 0810710092 Tita Luthfia S 0810710107 Anantika Putri 0810713004 Arrasyid Indra 0710713025 Pembimbing : dr. Munsifah Z., SpEM

FK UNIV. BRAWIJAYA/RSU DR. SAIFUL ANWAR MALANG 2013

Introduction
 Chest pain  many symptoms overlap  Goal in ED is to r/o life threatening causes of chest pain  Need appropriate history, physical exam, and ancillary tests

LIFE-THREATENING CAUSES
Acute myocardial infarction Unstable angina

Aortic dissection
Pulmonary embolism Tension pneumothorax Oesophageal rupture

NON LIFE-THREATENING CAUSES
Cardiac Stable angina Prinzmetal angina Pericarditis/myocarditis Simple pneumothorax Pneumonia with pleurisy Reflux oesophagitis Oesophageal spasm Gastritis/PUD Biliary disease Subphrenic abscess/inflammation

Respiratory Gastrointestinal Referred pain

Chest Pain .History  Time & character of onset  Quality  Location  Radiation  Associated Symptoms      Aggravating symptoms Alleviating symptoms Prior episodes Severity Review risk factors .

Pleurisy. Pericarditis. tearing. PTX  Esophageal: Burning  MI: squeezing. can also be burning  Sharp. ripping pain: Aortic Dissection .Time & Character of Onset  Abrupt onset with greatest intensity at start : Aortic dissection. pressure. tightness. Pneumonia. PTX. Occasionally PE will present in this manner  Chest pain lasting seconds or constant over weeks is not likely to be due to ischemia Quality  Pleuritic Pain: PE. heavy weight on chest.

COPD/Asthma Asymmetric leg swelling: DVT  PE With new onset neurologic findings or limb ischemia: consider dissection  Pain with swallowing. Pneumonia. vomiting. acid taste in mouth: Esophageal disease . consider chest wall pain or pain of pleural origin Associated Symptoms      Fevers. productive cough : Pneumonia Nausea. shortness of breath: MI Shortness of breath: PE. MI. PTX.Location  If very localized. chills. URI symptoms. diaphoresis.

pleurisy Palpation: Chest Wall Pain . consider pericarditis.Aggravating Symptoms        Activity: Consider ischemic heart disease Food: Consider esophageal disease Position: If worse with laying back. Pneumonia. PTX. Swallowing: Esophageal disease Movement: Chest wall pain Respiration: PE.

last stress test. etc  What diagnostic work-up have they had so far? Last ECG. esophageal pain. last cath. etc . echo.Alleviating Symptoms  Rest/ Cessation of Activity: Ischemic  Sitting up: Pericarditis  Antacids: Usually GI system Prior Episodes  Have they had this kind of pain before  Does this feel like prior cardiac pain.

DM. hypercoagulable state: PE  Uncontrolled HTN/ Marfan’s: Dissection  Rheumatic Diseases: Pleurisy  Smoking: COPD. tobacco. recent surgery or immobility.Severity  Severity of chest pain Risk Factor  Hypertension. car rides. Ischemia . family history  Long plane trips. high cholesterol.

Pneumonia * Check BP in both arms: Dissection * Decreased sats: More commonly in pneumonia. Tamponade. PE. COPD * Unexplained sinus tachy: consider PE  Neck * Look for tracheal deviation: PTX * Look for JVD: Tension PTX. (CHF) * Look for accessory muscle use: Respiratory Distress (COPD/ASTHMA) .Chest Pain – Physical Examination  Review vital signs * Fever: Pericarditis.

Chest Pain – Physical Examination  Chest wall exam * Look for lesions: Herpes Zoster * Palpate for localized tenderness: Likely musculoskeletal cause  Lung exam * Decreased breath sounds/hyperresonance: PTX * Look for Rhonchi: Pneumonia * Listen for wheezing/prolonged expiration: COPD .

Chest Pain – Physical Examination • Cardiovascular Exam * Assess heart rate * Listen for murmurs. S3/S4 * Pericardial friction rub: pericarditis * Muffled heart sounds: Tamponade * Assess distal pulses • Abdominal Exam * Assess RUQ and epigastrium • NEURO EXAM * Chest pain +neurologic findings: consider dissection .

Pneumothorax . Sputum cultures (pneumonia).Rib fractures . Cardiac Enzymes (MI).Chest Pain – Ancillary Tests LABS CBC. ESR (pericarditis) .Hampton’s Hump/Westermark’s sign: PE . Peak flow (Asthma). Blood cultures (pneumonia).Cardiac size: enlarged silhouette without CHF: pericardial effusion CXR ECG CT Scan MI CT Scan Thorax if suspect PE or Aortic Dissection . D dimer (PE).Widened mediastinum: Aortic dissection .Infiltrates: Pneumonia . ABG. PT/PTT.

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patient in distress and diaphoretic. bring patient to resuscitation area immediately  Put patient on oxygen supplementation. blood pressure monitoring  Set up IV line and take blood test  Give pain relief depending on provisional diagnosis .Management Non Traumatic Chest Pain  Ensure vital sign are stable. continuous ECG monitoring. If unstable. pulse oximetry.

Tanda dan Gejala • Nyeri dada tiba-tiba (menyebar ke lengan kiri atau leher sebelah kiri). vomiting. berkeringat.ACUTE MYOCARDIAL INFARCTION (AMI) Definisi • Sering disebut serangan jantung. sesak nafas. dan cemas. menyebabkan kematian sel jantung mati. palpitasi. . merupakan akibat dari gangguan aliran darah ke bagian jantung. nausea.

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repeat ECG after 5 minutes (to exclude ECG changes dt coronary spasm) Consider thrombolytic therapy Consider myocardial salvage therapy IV GTN 20-200 microgram/min .Management AMI O2 Aspirin 300320 mg CPG 300 mg S/L GTN 1 tab stat. increase by 510 microgram/min at 5-10 min intervals (if necessary) Morphine iv 2-5 mg slow bolus (if necessary) .

Indikasi Terapi Thrombolytic – Typical chest pain of AMI – ST elevation of at least 1 mm in at least 2 inferior ECG leads or elevation of at least 2 mm in at least 2 contiguous anterior leads – < 12 h from chest pain onset – < 75 y.o of age .

UNSTABLE ANGINA PECTORIS Rapid accumulation of platelets at the rupture site and a sudden increase in obstruction to blood flow in the coronary artery Unstable angina results from the sudden rupture of a plaque Accumulation of platelets and obstruction to blood flow can result in a heart attack Risk of heart attack remains even if the unstable angina symptoms lessen or disappear .

Gejala yang dirasakan : – Nyeri atau tertekan – Rasa berat dan tidak nyaman pada dada. leher. • Gejala lain yang bisa terjadi : – Mual – Nyeri kepala – Keringat berlebihan . bahu dan lengan – Rasa terbakar atau indigestion – Sesak • Unstable angina terjadi tanpa didahului tanda awal dan terjadi saat istirahat sehingga sering mengakibatkan ansietas.Tanda dan Gejala UAP • Bisa berlangsung selama 5-20 menit. kerongkongan.

Mengurangi resistensi pembuluh darah  mengurangi kerja jantung (workload) • Beta-blockers .Management UAP • Nitrates .Dilatasi pembuluh darah dan mengurangi tekanan darah .Memperlambat denyut jantung dan mengurangi tekanan kontraksi otot jantung • Calcium channel blockers .Dilatasi pembuluh darah .

Stasis. Hypercoagulability) .PULMONARY EMBOLISM (PE) • PE is a blockage of the main artery of the lung or one of its branches by a substance that has travelled from elsewhere in the body through the bloodstream (embolism) • Origin >> DVT Virchow’s Triad (Endothelial Injury.

Clinical Symptoms of PE Clinical symptoms suggestive of PE: • Dyspnea • Chest pain (Pleuritic/non pleuritic) • Cough • Orthopnea • Calf and/or thigh pain or swelling • Wheezing Common signs: • Tachypnea • Tachycardia • Rales • Decreased breath sounds • Jugular venous distension • Accentuated pulmonic component of second heart sound Symptoms/ signs of lower extremity DVT include : edema. . tenderness or a palpable cord. erythema.

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PE Management  Initiate Heparin .Make sure no intraparenchymal brain hemorrhage or GI hemorrhage prior to initiating heparin.Especially if PE + hypotension . initiate empiric heparin while waiting for imaging .Fractionated Heparin (Lovenox): 1mg/kg SubQ BID .If high pre-test probability for PE. then 18units/kg/hr .  Consider Fibrinolytic Therapy: .Unfractionated Heparin: 80 Units/Kg bolus IV.

PE Management  Surgery and Other Prosedure • Consider Clot removal. • Vein filter. doctor may thread a thin flexible tube (catheter) through blood vessels and suction out the clot. and the goal is to remove as many blood clots as possible. Filter insertion is typically reserved for people who can't take anticoagulant drugs or when anticoagulant drugs don't work well enough • Surgery. . especially if there's a large clot in main (central) pulmonary artery. For a very large clot in lung and in shock. IThis happens infrequently.

AORTIC DISSECTION • Aortic dissection is an acute event where blood enters the aortic wall through a tear of the intima followed by extravasation of blood into the media. • Currently believed the process begins with an intramural hematoma .

Etiology • • • • • • • • Degenerative Hypertension Pregnancy Skeletal (scoliosis) Connective tissue (Marfan’s) Mycotic aneurysm Takayasu (giant cell) arteritis Aortic laceration/coarctation .

arch & descending aorta – Type II –ascending only – Type III –descending only .Aortic Dissection • Stanford Classification – Type A -involves ascending aorta – Type B –involves descending aorta • DeBakey Classification – Type I –ascending.

Aortic Dissection Clinical Features >85% abrupt. severe pain in chest or b/w scapula 50% ripping or tearing Pain in anterior chest – ascending aorta (70%) Back pain (less common) – descending aorta (63%) If dissection into carotid classic neuro symptoms .

Aortic Dissection • Physical Exam – Usually normal heart and lung exam – May have aortic insufficiency – <20% with decreased radial. femoral or carotid pulse – Tachycardia – Hyper/Hypotension .

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8mg q10min to 300mg total Calcium channel blocker if -blocker contraindicated Surgery -blocker Nitroprusside 0.Aortic Dissection Vasodilator Treat hypertension • Esmolol 500g/kg IV bolus over 1 minute then 50150 g/kg minute • Metoprolol 5mg q2min x3 IV then 25mg/hr • Propranolol 20mg IV then 40mg.3 g/kg/min IV OR for ascending aortic dissection Descending aortic dissection worse surgical risks – controversial for repair .

TENSION PNEUMOTHORAX • Trachea deviates to contralateral side • Mediastinum shifts to contralateral side • Decreased breath sounds and hyperresonance on affected side • JVD • Treatment: Emergent needle decompression followed by chest tube insertion .

NEEDLE DECOMPRESSION Insert large bore needle (14 or 16 Gauge) with catheter in the 2nd intercostal space mid-clavicular line. . Remove needle and leave catheter in place. Should hear air.

. saluran nafas besar. diafragma.Nyeri dada pleuritik • Lokasinya posterior atau lateral. mediastinum dan saraf interkostalis. • Nyeri berasal dari dinding dada. pleura perietalis. iga. • Bertambah nyeri bila batuk atau bernafas dalam dan berkurang bila menahan nafas atau sisi dada yang sakit digerakan. otot. Sifatnya tajam dan seperti ditusuk.

menetap atau dapat menyebar ke tempat lain.pleuritik • Lokasinya sentral. .Nyeri dada Non. • Sering disebabkan oleh kelainan di luar paru.

Nyeri Dada Non Pleuritik Kardial Pulmonal Perikardial Fungsional Aorta Muskulo skleletal .

. terutama terjadi pada waktu menelan. • Nyeri dada merupakan keluhan utama pada kanker paru yang menyebar ke pleura. tulang kartilago sering menyebabkan nyeri dada setempat. dispnea. Fungsional • Kecemasan dapat menyebabkan nyeri substernal atau prekordinal.Muskulo skeletal • Trauma lokal atau radang dari rongga dada otot. palpilasi. Pulmonal • Obstruksi saluran nafas atas seperti pada penderita infeksi laring kronis dapat menyebakan nyeri dada. using dan rasa takut mati. organ medianal atau dinding dada. • Nyeri biasanya timbul setelah aktivitas fisik. • Pada emboli paru akut nyeri dada menyerupai infark miokard akut dan substernal. rasa tidak enak di dada.

tetapi dapat menyebar ke epigastrium. Angina tak stabil (Angina preinfark. Nyeri perikardila lokasinya di daerah sternal dan area preokordinal. trauma dinding dada merupakan resiko tinggi untuk pendesakan aorta. koartasio aorta. Angina of Effort). Infark miokard Perikardial • Saraf sensoris untuk nyeri terdapat pada perikardium parietalis diatas diafragma.Kardial • Angina stabil (Angina klasik. miring atau bergerak. bahu dan punggung • Nyeri bisanya seperti ditusuk dan timbul pada aktu menarik nafas dalam. menelan. Aorta • Penderita hipertensi. leher. • Diagnosa dicurigai bila rasa nyeri dada depan yang hebat timbul tiba.tiba atau nyeri interskapuler . Insufisiensi koroner akut) .