ER June 16, 2009

“CHEST PAIN”

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Stratification “RISK”
 Risk Factors
 Who gets what?

 List the risk factors  Clinical Suspicion

 Testing
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Chief Complaint
 What will be

presenting complaints?
 MALE  FEMALE

3

HPI
 What are the “KILLERS”
1. 2. 3. 4. 5. 6. 7. 8.

Myocardial infarction Dissecting aortic aneurysm Pericarditis with tamponade PE Pneumonia Tension pneumothorax Rupture esophagus (Boorhave’s syndrome) Cancer

 What are the “Most Commons”
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Causes
   

Acute Coronary Syndrome Aneurysm, Abdominal Aneurysm, Thoracic Angina Pectoris

   

Mitral Stenosis Mitral Valve Prolapse Multifocal Atrial Tachycardia Myocardial Infarction

   

Torsade de Pointes Transplants, Heart Ventricular Tachycardia Wolff-Parkinson-White Syndrome


          

Aortic Regurgitation
Aortic Stenosis Atrial Fibrillation Atrial Flutter Cardiomyopathy, Dilated Cardiomyopathy, Restrictive Congestive Heart Failure and Pulmonary Edema Dissection, Aortic Dissection, Carotid Artery Dissection, Vertebral Artery Heart Block, First Degree Heart Block, Second Degree


            

Myocarditis
Myopathies Congestive Heart Failure Pericarditis and Cardiac Tamponade Peripheral Vascular Disease Premature Ventricular Contraction Pulmonic Valvular Stenosis Shock, Cardiogenic Hypovolemica Sinus Bradycardia Superior Vena Cava Syndrome Syncope Tetralogy of Fallot Thoracic Outlet Syndrome


Heart Block, Third Degree
Mitral Regurgitation

5

Pulmonary
              

Pulmonary Asthma Bronchitis Chronic Obstructive Pulmonary Disease and Emphysema Hyperventilation Syndrome Pleural Effusion Pneumonia, Aspiration Pneumonia, Bacterial Pneumonia, Empyema and Abscess Pneumonia, Immunocompromised Pneumonia, Mycoplasma Pneumonia, Viral Pneumothorax, Iatrogenic, Spontaneous and Pneumomediastinum Pulmonary Embolism Pleuritic CP
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Musculoskeletal “Chest Wall Pain”
 11-50 %

 Trauma
 Costochondritis

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Other
 Psychological  GI Related
 GERD

 Undifferentiated

8

ROS
 Killers
 Cardio  Pulmonary

 Associations to DD
 Claudication (PAD) increased risk of CAD

 Most Common
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Past Medical History Surgical History
 Specifically ask about other disease processes

that increase the risk of whatever you are concerned about
   

DM HTN When was the last time you saw a doctor? Have you ever seen a doctor for blood pressure, cholesterol, or your heart ?
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Medications & Allergies
 Meds that alert you to increased risk  New Meds
 Antacids, ASA, “when & why did you start taking

that medication”

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Family History
 Tell me about your (mother, father, brothers,

sisters) health
 Specifically CAD, PAD, Age when problems

started or death

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Social History
 Occupation
 Stress

 Tobacco
 Pack years

 Alcohol  Do you use any street drugs
 If you want to know about Marijuana ?  ASK ABOUT COCAINE (re: B-Blocker)  UDS? Unopposed alpha receptors Auto matically do a drug screen
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Physical Exam
 Vitals and EKG  Constitutional  Skin (xanthoma, splinter hemorrhages)  Head  Eyes (copper wire)  ENT (ear creases)  Neck

 Heart
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Physical Exam
 Lungs  Abdomen  GU (not examined)  Musculoskeletal / Extremities  Neuro  Heme-Lymph  Psychiatric (anxious)

 Endocrine (thyroid, DM)
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Differential
 List 10

 Think about the HALMARKS of those ten
 Have you asked questions or performed a

physical exam that includes or excludes these
 If not what test do you need to
 Confirm your suspected diagnosis  Exclude the KILLERS
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ER Lab orders
     

CBC BMP LFT if indicated Lipase “CIP” “Cardiac Enzymes” PTT/PTT/ INR
 You need all three (unlike monitoring warfarin)

 BNP  D-Dimer (=/-)
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ER Orders Radiology
 Chest x-ray
 What are you looking for?  If you think chest pain is muscle pain are not getting a CT

 CT Scan-not used in everyone- if think they are

having N,
   

CT PE Study (CT Pulmonary Angiogram) CT Angiogram of the Aorta CT Angiogram of the Heart-specialized scanner CT TRIPLE RULE OUT-aorta angiogram abd aorta angiogram out PE

 Other test as indicated to rule out differentials  Pts are taken to cath lab every day on sxs alone.

They are not done emergency, price $1500

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ER Medication Orders
 ASA ON ARRIVAL  If EKG changes that indicate MI or Angina, or High Clinical

Suspicion go right to the ACS PROTOCOL and Notify Cardiology

 Remember CXR BEFORE Starting Heaprin  https://www.musc.edu/cce/ORDFRMS/pdf/cpedadmit.pdf  https://www.musc.edu/cce/ORDFRMS/pdf/ah_card_cardiologyhe

parinprotocol.pdf

 Nitroglycerine (based on suspicion)
 0.4 mg SL-see if it helps pain can also help with esophageal pain

as well  1-2 inches of paste to chest  IV Infusion (drip) 5 or 10 micrograms / min

 You will titrate this to pain AND BP or hypotensive
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ER Chest Pain Workup
 Oxygen  Nitroglycerine (based on suspicion)
 0.4 mg

 GI Cocktail  EKG  CXR  CMB, BMP, Trop, INR, UDS, D-Dimer

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21

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Delta (change)
 An approach using the change in biomarkers over two hours was

investigated in a comprehensive strategy of chest pain testing. There was a 93 percent sensitivity for acute myocardial infarction within 24 hours using a two hour strategy incorporating baseline ECG, cardiac markers, two hour delta CK-MB, two hour delta troponin and serial ECGs

 In a similar investigation, delta CK-MB was more accurate than

myoglobin for diagnosing early myocardial infarction.

However, the sensitivity of the delta CK-MB varied from 73 to 93 percent depending on the cutoff used, emphasizing the importance of using an appropriate threshold for a positive change

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Now What?
 When you have positive findings its easy  What if everything is normal-what do you do, a lot is clinical

suspicion, we can call cardiologist and see if they will hold overnight and stress test the pt. PA may stress them and they send them to

 Admit-If having a stemi, unstable angina  Discharge
 

Medicine follow up Cardiology follow up

 ____ hrs. observation
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Should I stay or should I go?
 CP with identified cause
 Depend on the cause

 CP with ekg changes  CP 1 risk factor  CP 2 risk factors  CP 3 risk factors  CP 4 risk factors

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Escalating the outpatient workup
 H &P / Risk factors  REVIEW OF RECORDS

 EKG & CXR
 Compare to previous  Early pathology may not show up

 Resting EKG

Functional testing
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Functional Testing
 Stress
 Walking or nuclear  Stress echo  Wall motion abnormality

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Cardiac Catheterization
 Virtual
 TRO  heart center

 Real

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Outpatient
 Stress Testing  Holter Monitor (24-48 hrs)  Event Monitor (30 days)  Tilt Table-look up  EP Studies-look up

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Observation

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ER Discharge
 Follow up

 Further testing-OP stress test
 B-Blocker for HTN  ASA daily until follow up  Return for:
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