20/20: 'DEADLY 6' of CHEST PAIN
Published on Sep 19, 2016
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PRESENTATION OUTLINE
CP CASE - 1
- 55yo F airline attendant
- CC: pleuritic chest pain, SOB, hemoptysis
- PMH : Appendicitis 4 weeks ago, OCP use
- SH : Smokes 1 PPD, no exercise, sexually active
- VS : T - 99.1, HR - 105, BP - 89/61, RR - 21, O2 - 94%
Photo by Stuck in Customs
P - PULMONARY EMBOLISM
Photo by Stuck in Customs
P - PULMONARY EMBOLISM
- CP - Pleuritic c/p, SOB, hypoxia, low O2 sat
- Dx - ECG (tachy), CTA, V/Q Scan, D-dimer
- Tx - O2, IVF, Heparin, tPA (if severe)
- PEARL: PERC CRITERIA ("HADCLOTS")
PERC Criteria: "HAD CLOTS" - Hormone use, Age >50, DVT Hx, Cough blood, Leg swelling (unilateral), O2 sat 100, Surgical hx
Photo by Stuck in Customs
CP - Case 2
- 36yo M painter
- CC: burning chest pain, hematemesis following 3 episodes of forceful vomiting
- PE - toxic appearing, lethargic, HoTN
- SH - drinks 6 pack on weedays, "benders' on weekends
- PE - toxic appearing, lethargic, HoTN
Image courtesy of Dr Matt A. Morgan, Radiopaedia.org, rID: 45380
E - ESOPHAGEAL RUPTURE
(Boerhaave Syndrome)
Esophageal rupture - rupture of the esophageal wall.
Boerhaave Syndrome - reserved for the 10% of esophageal perforations which occur due to vomiting.
Boerhaave Syndrome - reserved for the 10% of esophageal perforations which occur due to vomiting.
E - ESOPHAGEAL RUPTURE
- CP: hematemesis, c/p, forceful vomiting
- Dx: CXR (free air under diaphragm)
- Tx: ABC's, IVF, broad-spect AB's, analgesics, surgery
- Pearl: Boerhaave's = esophageal rupture from vomiting (alcoholics)
CP Case - 3
- 18yoM skateboarder
- CC: sudden onset c/p, SOB after falling off skateboard jump
- PMH/PSH - none
- PE - HoTN, RR - 24, absent BS on R side
Photo by Manny Valdes
T - TEnsion Pneumothorax
Photo by Manny Valdes
T - TEnsion Pneumothorax
- CP: Penetrating or blunt trauma, SOB
- Dx: CXR*
- Tx: Needle decompression @ midclavicular line; Tube thoracostomy in 4th IC space @ midaxillary line
- Pearl: Ehlers-Danlos have higher risk
* This is actually a clinical diagnosis based on history and patient presentation. Many attendings will say that if you diagnose this on a CXR (ie, you missed the clinical diagnosis), you missed it.
Photo by Manny Valdes
CP case - 4
- 50yo M elementary teacher
- CC - sudden onset dull c/p, radiating to L shoulder, worse w/exertion, +n/v, diaphoresis
- PMH - HTN, DM, HLD
- SH - 20PY smoke hx, poor diet and exercise
Photo by Tojosan
M - Myocardial Infarction
- CP: sudden onset dull c/p ("fist-like"), radiating to L shoulder, worse/w exertion, +n/v, diaphoresis
- Dx: EKG (STE's in 2 contiguous leads), trops/CK-MB
- Tx: MONAB - Morphine, O2*, NTG (s/l), ASA, BB's + Heparin/PCI
- Pearl: F's, diabetics more likely to have 'atypical" presentation
Routine oxygen therapy in acute MI settings is a common practice. Whereas hypoxemic patients undoubtedly benefit from oxygen insufflation, the level of evidence for this practice in normoxemic patients is insufficient to determine its efficacy and safety (Shuvy, 2013).
Oxygen therapy in acute coronary syndrome: are the benefits worth the risk? You have access
Mony Shuvy, Dan Atar, Philippe Gabriel Steg, Sigrun Halvorsen, Sanjit Jolly, Salim Yusuf, Chaim Lotan
DOI: http://dx.doi.org/10.1093/eurheartj/eht110 1630-1635 First published online: 3 April 2013
Oxygen therapy in acute coronary syndrome: are the benefits worth the risk? You have access
Mony Shuvy, Dan Atar, Philippe Gabriel Steg, Sigrun Halvorsen, Sanjit Jolly, Salim Yusuf, Chaim Lotan
DOI: http://dx.doi.org/10.1093/eurheartj/eht110 1630-1635 First published online: 3 April 2013
Photo by Tojosan
cp Case - 5
- 56yo M stockbroker, recent cocaine use
- CC: tearing chest pain, radiate to back
- PMH - HTN (poor med compliance)
- SH - 10y social cocaine use, stock broker
Photo by Sharon Drummond
A - AORTIC DISSECTION
Photo by Sharon Drummond
A - AORTIC DISSECTION
- CP: Tearing c/p, radiating to back; hx HTN
- Dx: Unequal L/R arm BP's; TEE, CTA
- Tx: surgery or B-Blockers*
Aortic Dissection - Tear in the intima due to shear wall stress that progresses into the media. Creates false lumen and true lumen that cant be seen with contrast.
Tx with surgery or b-blockers based on type:
Stanford A - involves the asc/arch -> surgery
Stanford B - begins in desc aorta, distal to the takeoff of the left subclavian artery -> B-Blockers
Tx with surgery or b-blockers based on type:
Stanford A - involves the asc/arch -> surgery
Stanford B - begins in desc aorta, distal to the takeoff of the left subclavian artery -> B-Blockers
Photo by Sharon Drummond
CP Case - 6
- 60yo F, restrained driver in MVA 1 DA
- CC: slow onset dull c/p, light headed, SOB
- VS: BP - 89/62, HR - 86, RR - 19, 98% RA
- PE - JVD, muffled heart sounds
- EKG - low-voltage, alternating QRS amplitude
Photo by avlxyz
C - Cardiac TAMPONADE
- CP: C/P, Beck's Triad (HoTN, Muffled HS's, JVD)
- Dx: EKG (low voltage, cardiac alternans), ECHO
- Tx: IVF bolus, Pericardiocentesis
- Pearl: slow bleeds/effusions can build upper greater volume prior to symptom onset
Cardiac Alternans - due to the swinging motion of the heart in the pericardial cavity causing a beat-to-beat variation in QRS axis and amplitude.
Patients with cardiac tamponade and hemodynamic compromise should have emergency pericardiocentesis.
Patients with cardiac tamponade and hemodynamic compromise should have emergency pericardiocentesis.
Photo by avlxyz
summary-Deadly 6
- Pulmonary embolism
- Esophageal rupture
- Tension pneumothorax
- Myocardial infarction
- Aortic dissection
- Cardiac tamponade
Photo by Leo Reynolds
