1. Chest Pain Intern Report Curriculum

2. Five point approach 1: ECG 2:History Most diagnoses are clear from a good history 3: Physical exam 4: CXR 5: Labs

3. Sick vs. Not Sick 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!

4. History: listen to the patient! Let the patient describe symptoms – few will say “I’m having chest pain” Discomfort Heaviness Squeezing Pressure Tightness Burning Indigestion Quickly find out what chronic conditions the patient has: CAD –CABG, PCI DM2 HTN PAD COPD GERD CKD

5. History: Questions to ask #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)

6. History: Questions to ask 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)

7. Physical exam Obtain vital signs and look at the patient Respiratory distress, diaphoresis, alertness Pulmonary exam Crackles, wheezes, decreased breath sounds Cardiac exam Assess JVP!JVP Palpate carotids – note rate and rhythm Palpate the precordium Listen for murmurs and S3/S4S3/S4

8. Killip Classification for Acute MI ClassPhysical Exam30 Day Mortality INormal<5% IIJVD, + S315% IIIPulmonary Edema30% IVCardiogenic Shock40%

9. ECG Take at least 1 minute to read the entire ECG Look for ST segment changes or new LBBB Other clues: T-wave inversion or peaking Q waves (old MI) Conduction abnormality (new BBB or AVB) Axis deviation

10. What is the diagnosis?

11. LBBB (Beware of the new LBBB!)

12. CXR Systematic evaluation 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

13. Labs Troponin Most sensitive for cardiac damage Repeat after 6-12 hours CKMB Helps determine timing of cardiac event BNP? Typically NOT useful for workup of chest pain Others in case of urgent intervention CBC, INR, PTT, BMP, beta-hCG

14. Elevation of Cardiac Biomarkers http://www.publicsafety.net/image/graph.jpg

15. Differential diagnosis What is your DDX for Emergent Chest pain?

16. JAMA 1998; 280:1256-1268

17. Emergent dx: tension pneumothorax Absent breath sounds unilaterally Respiratory distress Tracheal deviation Hypotension NO TIME FOR CXR Tx: Immediate placement of large bore catheter needle @ 2 nd intercostal space (midclavicular line)

18. What is the diagnosis?

19. Inferior STEMI

20. Emergent dx: aortic dissection 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

21. Emergent dx: aortic dissection NO ENOXAPARIN NO HEPARIN NO CLOPIDOGREL Emergent cardiac surgery consultation Mortality is 1-2% per hour for Type A 50% die within 48h Esmolol drip – FIRST! Titrate to HR 60s Consider nitroprusside AVOID HYDRALZINE

22. What is the diagnosis?

23. Anterior STEMI (Transmural)

24. Emergent dx: STEMI 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)

25. What is the diagnosis?

26. NSTEMI – Anterior Subendocardial Ischemia

27. What portion of heart not seen well on ECG?

28. Urgent dx: NSTEMI 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 Metoprolol (goal HR 60s) Heparin drip Consider enoxaparin GP IIb/IIIa inhibitor – usually Integrilin CAUTION Clopidogrel – load with 600 mg PO x 1

29. Urgent dx: pulmonary embolism Immobilized pt (ortho?) Evidence for DVT Acutely SOB Hypoxemia High suspicion: PE protocol CT or VQ scan Low suspicion: check D- dimer and LE Dopplers If no contraindication and suspicion is high, begin treatment right away! IV heparin Consider enoxaparin Warfarin ICU if hemodynamically unstable Consider IVC filter if pt cannot be anticoagulated

30. What is the diagnosis?

31. Acute Pericarditis!

32. Other diagnoses 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