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Published byGillian Aileen Atkinson Modified over 9 years ago
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An introduction to Chest pain ‘how to mend a broken heart’
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Case 1 55 year old accountant Stressed in a meeting at work Sudden onset chest pain
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Crushing chest pain…
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ECG
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Coronary artery thrombus
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Immediate treatment Oxygen Analgesia Aspirin Thrombolysis ‘clot busting drugs’ Primary angioplasty ‘hot wiring’
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Another Case Reg G 61 year old retired suffolk farmer Osteoarthritis hip Undergoes total hip replace (THR)
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4 days post-op Initially making good recovery Sudden onset SOB and sharp ‘stabbing’ chest pain on commode in the evening O 2 sats 89% on air Pulse 130 bpm irregularly irregular
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What may have happened?
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Immediate investigations
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ECG
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Immediate management
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D-Dimer Specific degradation product released into circulation when cross-linked fibrin undergoes endogenous fibrinolysis Low D-dimer has high negative predictive value Non-specific elevation in sepsis, pregnancy, MI and post surgery
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CXR
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Imaging CXR – to exclude other causes CTPA –CT chest –Give iv iodine and time to fill pulmonary arteries –Arm vein -> RA -> RV -> PA Contrast can –Cause allergic reaction –Damage kidneys
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What are we looking for?
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Imaging – Pulmonary angiogram
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Treatment
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Oxygen to correct hypoxia LMWH – dose according to weight Commence warfarin loading 6 months treatment with warfarin
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What would you warn Reg about the risks of treatment?
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Case 3 – Mr AL 21 year old man Known Marfan’s disease Previous aortic valve replacement Acutely SOB R-sided chest pain
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Examination findings In pain and distressed RR 30 / min Oxygen saturation 85% on air Hyper-resonant over R lung field Increased SOB
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Radiology Right lung: –Black –No markings –No mediastinal shift Sternal wires Heart valve Pleura
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Treatment
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Further radiology – post chest drain Pleura
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What does the future hold Must not scuba dive High chance of recurrence if at increased altitude – no flying for at least 1/12 Chance of recurrent pneumothorax high
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Any questions?
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