Transcript Preoperative Evaluation and Risk Assessment in the Cardiac

Chest Pain
Intern Report Curriculum
Five point approach
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ECG
 2:History
• Most diagnoses are clear from a good history
 3:
Physical exam
 4: CXR
 5: Labs
Sick vs. Not Sick
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Evaluate need for emergent care and associated
emergent management
• Guided by Focused History and Physical, along with
ECG and chest radiograph
• Awaiting labs may not be appropriate in emergent
situations
• If patients are sick and may need emergent
intervention, always get your resident, fellow, etc.
involved early!
History: listen to the patient!
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Let the patient describe
symptoms – few will say
“I’m having chest pain”
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Discomfort
Heaviness
Squeezing
Pressure
Tightness
Burning
Indigestion
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Quickly find out what
chronic conditions the
patient has:
• CAD
– CABG, PCI
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DM2
HTN
PAD
COPD
GERD
CKD
History: Questions to ask
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#1: Are you having chest pain right now? (acuity)
 Have you ever had pain like this before? (history)
 When did the pain start? (timing)
 What were you doing when the pain started?
(association with activity)
 How would you describe the pain? (quality)
History: Questions to ask
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How would you rate the pain (1-10)? (quantity)
 Can you point to the pain? (location)
 Does the pain go to your back, neck, or arm?
(radiation)
 Were there other symptoms that accompanied the
pain? (SOB, diaphoresis, nausea, lightheadedness,
palpitations)
 Is there anything that makes the pain better or
worse? (deep breaths, sitting up/lying down,
SLNTG)
Physical exam
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Obtain vital signs and look at the patient
• Respiratory distress, diaphoresis, alertness
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Pulmonary exam
• Crackles, wheezes, decreased breath sounds
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Cardiac exam
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Assess JVP!
Palpate carotids – note rate and rhythm
Palpate the precordium
Listen for murmurs and S3/S4
Killip Classification for Acute MI
Class
Physical Exam
30 Day Mortality
I
Normal
<5%
II
JVD, + S3
15%
III
Pulmonary Edema
30%
IV
Cardiogenic Shock
40%
ECG
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Take at least 1 minute to read the entire ECG
Look for ST segment changes or new LBBB
Other clues:
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T-wave inversion or peaking
Q waves (old MI)
Conduction abnormality (new BBB or AVB)
Axis deviation
What is the diagnosis?
LBBB (Beware of the new LBBB!)
CXR
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Systematic evaluation
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Quick overview for glaring abnormalities
Technique
Skeleton (fractures, dislocations, lytic lesions)
Abdomen (diaphragm, stomach)
Airway/mediastinum
Heart size and shape
Lungs
– Pneumothorax, infiltrates, edema, effusions
Labs
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Troponin
• Most sensitive for cardiac damage
• Repeat after 6-12 hours
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CKMB
• Helps determine timing of cardiac event
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BNP?
• Typically NOT useful for workup of chest pain
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Others in case of urgent intervention
• CBC, INR, PTT, BMP, beta-hCG
Elevation of Cardiac Biomarkers
http://www.publicsafety.net/image/graph.jpg
Differential diagnosis
What is your DDX for
Emergent Chest pain?
JAMA 1998; 280:1256-1268
Emergent dx: tension pneumothorax
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Absent breath sounds
unilaterally
Respiratory distress
Tracheal deviation
Hypotension
NO TIME FOR CXR
Tx: Immediate placement of
large bore catheter needle
@ 2nd intercostal space
(midclavicular line)
What is the diagnosis?
Inferior STEMI
Emergent dx: aortic dissection
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Acute “tearing” chest
pain radiating to the
back
Usually hypertensive
Widened mediastinum
Differential arm BPs
Confirmed by CT chest
(dissection protocol) or
TEE (renal failure)
MRI: takes too long
Emergent dx: aortic dissection
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NO ENOXAPARIN
NO HEPARIN
NO CLOPIDOGREL
Emergent cardiac surgery consultation
• Mortality is 1-2% per hour for Type A
• 50% die within 48h
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Esmolol drip – FIRST!
• Titrate to HR 60s
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Consider nitroprusside
AVOID HYDRALZINE
What is the diagnosis?
Anterior STEMI (Transmural)
Emergent dx: STEMI
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Immediately page CCU fellow
 ASA 325 mg
 NTG (SL then drip; remember SL more potent!)
 Metoprolol (IV): goal HR 60s, SBP >100
 Heparin drip (anti-thrombin)
 Plavix load-600mg
 Pt needs recent CBC, PTT, INR, BMP
 Ask about contrast allergy
 Cath lab immediately (usually)
What is the diagnosis?
NSTEMI – Anterior Subendocardial Ischemia
What portion of heart not seen
well on ECG?
Urgent dx: NSTEMI
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Immediate goal: relieve angina
ASA 325 mg
NTG: SLNTG, then IV nitro if needed
• If patient can not be made pain-free, may need cath lab
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Metoprolol (goal HR 60s)
Heparin drip
• Consider enoxaparin
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GP IIb/IIIa inhibitor – usually Integrilin
CAUTION
Clopidogrel – load with 600 mg PO x 1
Urgent dx: pulmonary embolism
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Immobilized pt (ortho?)
Evidence for DVT
Acutely SOB
Hypoxemia
High suspicion: PE
protocol CT or VQ scan
Low suspicion: check Ddimer and LE Dopplers
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If no contraindication and
suspicion is high, begin
treatment right away!
IV heparin
• Consider enoxaparin
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Warfarin
ICU if hemodynamically
unstable
Consider IVC filter if pt
cannot be anticoagulated
What is the diagnosis?
Acute Pericarditis!
Other diagnoses
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Acute pericarditis
 Hypertensive urgency
 Pneumonia
 Esophageal disease (incl. GERD, esophageal
spasm, Mallory-Weiss tear, Boerhaave’s
syndrome)
 Costochondritis
 Other GI (gastric/peptic ulcers, pancreatitis)
 Herpes zoster