Download chest pain module - UNM Hospitalist Wiki

Resident Version
Chest Pain Module
created by Dr. David Stevens
Objectives:
1) You will be able to appropriately evaluate a patient who complains of chest pain.
2) You will be able to recognize chest pain as typical or atypical of an Acute
Coronary
Syndrome.
3) You will be able to utilize tests and empiric therapy to differentiate and treat
chest pain.
4) You will understand the implications of tests and the need for further evaluation.
References:
1. Haro L, Wyatt W, Boie E, Wright R. Initial Approach to the Patient who has
Chest Pain. Cardiol Clin 2006; 24: 1-17.
2. Lee T, Goldman L. Evaluation of the Patient with Acute Chest Pain. NEJM
2000; 342 (16); 1187-1195.
A. OVERVIEW OF CHEST PAIN
Chest pain is a common complaint among patients on hospital wards and in medicine
clinics. Due to its association with the Acute Coronary Syndrome (“ACS”) and several
other life threatening diseases, it is essential to recognize the qualifying symptoms of
chest pain that make it more typical of life threatening diseases than of those which are
not life threatening. Table 1 below differentiates symptoms typical of ACS versus those
of other causes of chest pain. Common life threatening causes of chest pain include
ACS, dissecting aortic aneurysm, pulmonary embolism, pericarditis with tamponade
physiology and tension pneumothorax. Common causes of chest pain which are typically
non-life threatening include musculoskeletal pains, gastroesophageal reflux disease,
esophageal spasm, peptic ulcer disease, and herpes zoster in which pain antedates the
onset of typical rash.
A further consideration is that many patients seeking care in hospitals and clinics have
several risk factors which increase the likelihood that they have underlying coronary
artery disease or they may have other diseases which predispose them to worse clinical
outcomes (cancer, COPD, and various causes of immunodeficiency).
Table 1.
Symptoms of Acute Coronary Syndrome
Aggravated by Exertion
Relieved by Rest or Nitroglycerin
Location: Substernal
Quality: Pressure-like
Constant in Nature
Radiation: to Neck, Jaw, or Left Arm
Associated symptoms: Dyspnea, Diaphoresis,
Palpitations, Dizziness, Nausea
Onset: at rest or with exertion, gradual vs.
sudden
Symptoms of Other Types of Chest
Pain
Dissecting Aortic Aneurysm: Sharp,
stabbing, with radiation to back, acute
onset, may be associated with syncope
Pericarditis: associated viral syndrome
common, pleuritic, relieved by leaning
forward
Pulmonary Embolism: sharp, pleuritic,
sudden onset
Pneumothorax: spontaneous vs.
traumatic, associated dyspnea, pleuritic
pain.
Chest Wall Pain: associated trauma,
localized, reproducible with palpation
Esophageal Spasm: sudden onset,
relieved by nitroglycerin
GERD: burning sensation, sour taste in
mouth, aggravated by lying flat, spicy
foods
PUD: relieved by food or antacids
B. CLINICAL ASSESSMENT OF THE PATIENT:
Your approach to the patient reflects your need to determine if the patient is having a life
threatening cause of chest pain or any of the multitudes of non-life threatening causes.
You also need to determine if the chest pain is a symptom of a disease that requires
further evaluation.
1. Who is the patient? How old are they? Do they have known CAD or prior
DVT/PE? What symptoms do they have? What symptoms do you elicit by
questioning related to the above table?
2. What risk factors do they have for coronary artery disease?
Male >55yo, Female >65yo, diabetes, smoking history, hyperlipidemia,
hypertension, family history of CAD in 1st degree relative (Male <50yo, Female
<60yo)
3. Vital Signs: Are they clinically stable? Are they tachycardic, hypo/hypertensive,
tachypneic, hypoxic?
4. Physical Exam:
a) Do you find evidence of cardiac ischemia leading to heart failure?
Elevated JVP, third or fourth heart sounds, crackles in lungs, symmetric leg
edema, mitral regurgitant murmur (papillary muscle dysfunction)
b) Do you find evidence of another cardiovascular abnormality?
Irregular heart beat, tachycardia/bradycardia (arrhythmia?)
Different blood pressures in arms (thoracic aortic dissection)
Decreased blood pressures in legs compared to arms (abdominal aortic dissection)
c) Do you find evidence of pulmonary disease?
Crackles/dullness/changes in fremitus (pneumonia or effusion)
Decreased breath sounds, asymmetric/tympanic chest (pneumothorax)
d) Do they have an essentially normal physical exam?
5. Testing:
a) The first step is to evaluate cardiac causes of chest pain with an EKG!
Do they have an abnormal EKG? Rhythm, Rate, Intervals, Ischemic changes (ST
depression/inverted T waves), Evidence of prior myocardial infarction (Q waves),
new LBBB, or ST elevation!
b) The second step is to evaluate pulmonary causes of chest pain with a
CHEST RADIOGRAPH!
Do they have respiratory complaints? (dyspnea, cough, sputum production)
Do they have an abnormal cardiac or chest exam?
Are they hypoxic? (oxygen saturation <90% on room air)
*Obtain a STAT Portable Chest xray if patient is NOT stable or you may send patient
for a STAT PA/Lateral Chest xray if they are clinically stable)
*Chest radiographs may illustrate opacities consistent with pneumonia or effusion, a
widened mediastinum consistent with aortic dissection, lucencies consistent with
pneumothorax, or cardiomegaly.
*If patient is hypoxic, obtain an Arterial Blood Gas (ABG). Diagnosis of pulmonary
embolus (“PE”) will require further imaging with either VQ scan, or PE protocol Chest
CT scan.
C. TREATMENT:
By now you should have the information you need to determine what treatment you
should initiate for the patient. The main point is to first initiate therapies required to
make the patient clinically stable (IV fluid boluses, oxygen) and second to contact
whomever you require to implement further specialized interventions such as Cardiac
Catheterization, Surgery, Thoracostomy Tube placement.
a) ACS: “MONA” Morphine, Oxygen, Nitrates, Aspirin. Begin with sublingual
nitroglycerin q5minutes until PAIN FREE, ASA 325mg orally (chewed by patient),
oxygen via nasal cannula and morphine if continued chest pain. Obviously you will
contact your Resident IMMEDIATELY to implement further therapies (Beta Blockers,
Heparin IV infusion Nitroglycerin IV infusion if pain persists despite sublingual
Nitroglycerin, GP2B3A inhibitors), investigation with Cardiac Catheterization, and
transport to higher level of care (the CCU). Guaiac patient’s stool and ask about recent
bleeding/trauma/surgeries PRIOR to initiation of Heparin or other medications which will
predispose the patient to bleeding.
b) Pneumothorax: Oxygen at high flow (Face Mask), if tension pneumothorax is
present, the patient requires immediate intervention with large bore needle/angiocatheter
placement at anterior second intercostal space into the pleural space which must be left in
place until a thoracostomy tube is placed.
c) Dissecting Aortic Aneurysm: Large bore IVs placed bilaterally and fluid
resuscitation and blood pressure control with IV medications. STAT Vascular Surgery
consult. Transport to ICU status care.
d) Pulmonary Embolism: Oxygen, guaiac stool and ask about recent
bleeding/surgeries/trauma PRIOR to initiation of Heparin IV infusion.
e) If symptoms are more consistent with gastrointestinal complaints and vital
signs, physical exam, and EKG are normal, consider empiric therapy with antacids and
monitor patient for response.
f) Regardless of the diagnosis you make, look up appropriate therapies in a
readily available resource such as the Washington Manual or UpToDate.
D. CLINICAL CASE:
66yo male with h/o CAD on aspirin, metoprolol, and atorvastatin who presented to the
hospital three days ago with a copd exacerbation and has improved in clinical status since
admission though continues to require 4liters of oxygen via nasal cannula per minute and
q4hour nebulizers with albuterol and atrovent. He is tolerating oral prednisone at 40mg
daily and being treated with oral doxycycline. You are called by the night nurse to
evaluate the patient for new onset chest pain.
The patient states the chest pain began gradually while at rest following a nebulizer
treatment and radiates to his left neck and left arm.
Exam: Temp 98.9, p 120, bp 145/90, rr 24, 0xygen saturation 88% on 4lnc
Gen: mild distress
Cor: tachycardic, regular no murmur/rub/gallup, jvp 8cm
Chest: prolonged expiratory phase, no crackles or wheezes
Abd: soft, nontender, nondistended, normal active bowel sounds
Ext: 1+ bilateral lower extremity edema to knees
EKG: sinus tachycardia with ST depressions in leads I and AVL. Review of EKG at time
of admission reveals normal sinus rhythm heart rate 80bpm without ST changes.
CXR Portable: hyperinflated lungs, no opacities
WHAT IS YOUR DIAGNOSIS?
HOW DO YOU DIFFERENTIATE CARDIAC ISCHEMIA FROM NON ST
ELEVATION MI?
WHAT TREATMENT DO YOU INITIATE IMMEDIATELY?
WHAT IS THE CAUSE OF THIS PATIENT’S ACS?
E. BOARD REVIEW QUESTIONS:
1. A 57yo male patient with h/o hypertension and dyslipidemia is brought to the
emergency department by ambulance following an episode of chest pain which began
while walking to the kitchen. The chest pain began suddenly in the center of his chest
and radiates to his back. He describes the pain as sharp in nature and he has experienced
several similar though not as severe pains over the last week. His vital signs are as
follows. Temp 98.0F, pulse 95, bp 175/95, rr 16, oxygen saturation 85% on room air.
Physical exam reveals a regular rate and rhythm with a 2/6 diastolic murmur over the
right upper sternal border. He has 2+ radial pulses and carotid pulses bilaterally with
diminished pulses over bilateral femoral arteries. Lungs have bibasilar crackles.
What medication regimen would you begin first?
A) Heparin intravenously and concomitant aspirin by mouth
B) Digoxin intravenous loading dose
C) Diltiazem intravenously
D) Nitroprusside intravenously with concomitant beta blocker
2. A 65yo female presents to the emergency department with a chief complaint of chest
pain which began gradually over the last week which is associated with muscle aches and
chills and rhinorrhea. She describes onset of fevers three days prior to presentation with
temperature 101F at home. Her pain is non-radiating and increases with inspiration. Her
vital signs in the emergency department are as follows: Temp 99.0F, pulse 80, bp 135/80,
rr 16, oxygen saturation 92% on room air. Physical exam reveals a regular rate and
rhythm with no murmurs or rubs and no elevation of jugular venous pressure. Chest is
clear to auscultation. Her abdomen is soft, nontender, nondistended with normoactive
bowel sounds. Extremities are without edema.
An EKG reveals NSR with ST elevation in leads I, II, III, V2, V3, V4
What medication would you initiate for treatment of this patient’s condition?
A) Heparin intravenously
B) Prednisone by mouth
C) Ibuprofen by mouth
D) Coumadin by mouth
Post Module Evaluation
Please place completed evaluation in an interdepartmental mail envelope and address to
Dr. Wendy Gerstein, Department of Medicine, VAMC (111).
1) Topic of module:__________________________
2) On a scale of 1-5, how effective was this module for learning this topic? _________
(1= not effective at all, 5 = extremely effective)
3) Were there any obvious errors, confusing data, or omissions? Please list/comment
below:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
4) Was the attending involved in the teaching of this module? Yes/no (please circle).
5) Please provide any further comments/feedback about this module, or the inpatient
curriculum in general:
6) Please circle one:
Attending
Resident (R2/R3)
Intern
Medical student