Download ChestPain

Chest Pain
What must we learn?
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Epidemiology
Pathophysiology
Diagnostic Approach
Diagnostic Table
Management and Disposition
‫‪Case‬‬
‫آقاي ‪ 42‬ساله با شكايت درد قفسه سينه از شب گذشته به بخش اورژانس‬
‫مراجعه نموده است‪ .‬بيمار ذكر مينمايد از شب گذشته درد هايي در سمت چپ‬
‫قفسه سينه دارد كه در حدود ‪ 1‬دقيقه طول ميكشد ماهيت تيزدارد به محل‬
‫خاصي تير نميكشد و در حالت استراحت و فعاليت تفاوتي نمينمايد‪ .‬درد ها از‬
‫شب گذشته مكررا تكرار شده همراه با انها تهوع استفراغ و تعريق را ذكر‬
‫نمينمايد‪.‬درد با تنفس عميق تشديد ميشود‪ .‬بيمار محل درد را نقطه اي در زير‬
‫نيپل چپ نشان ميدهد‪.‬‬
‫بيمار سابقه بيماري خاصي را ذكر نميكند بجز سرماخوردگي در چند روز اخير‬
‫همچنين داروي خاصي نيز مصرف نمينمايد‪.‬‬
‫سابقه مصرف سيگار الكل و مواد مخدر را هم نميدهد‪.‬‬
‫در معاينه ديسترس خمصي ندارد‬
‫) ‪BP= 110/85 mmHg PR=92/ Min RR= 16/Min T= 37.1 c ( oral‬‬
‫در معاينه بجز تندرنس موضعي بر روي ناحيه ‪ Apical‬نكته حاصي ندارد‪.‬‬
‫تشخيس شما چيست؟‬
Epidemiology
> 5 million/year patients of
Emergency rooms
 A symptom caused by several life
threatening disease
 Accurately discerning the correct
diagnosis and treatment of a chest
pain is one of the most difficult tasks
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Epidemiology
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Catastrophic causes are:
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Acute coronary syndromes (ACS)
Aortic dissection
Pulmonary embolus
Pneumothorax
Pericarditis with tamponade
Esophageal rupture
ACS is the most significant potential diagnosis
Emergency physicians reportedly have missed 3%
to 5% of MI accounting for 25% of malpractice
Most of the chest pains presenting to the ED have
a benign origin
Pathophysiology
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Afferent fibers from the heart, lungs, great
vessels, and esophagus enter the same
thoracic dorsal ganglia.
Dorsal segments overlap three segments
above and below a level
Disease of a thoracic origin can produce
pain anywhere from the jaw to the
epigastrium
Radiation of pain is explained by somatic
afferent fibers synapsing in the same
dorsal root ganglia
Pathophysiology
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The quality of visceral chest pain has
been described as:
 Burning
 Aching
 Stabbing
 Pressure
Typical ischemic chest pain
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Retrosternal chest pressure
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Burning or heaviness
Radiating occasionally to neck, jaw,
epigastrium, shoulders, or left arm.
Precipitated by exercise, cold
weather, or emotional stress
Duration 2-10 minutes
Atypical Chest Pain
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Pleuritic chest pain
In the middle or lower abdominal region.
Localized at the tip of one finger,
particularly over the left ventricular ( LV )
apex.
Reproduced with movement or palpitation
of chest wall or arms.
Constant for many hours
Very brief episodes
Radiates into the lower extremities
Diagnostic Approach
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Rapid Assessment and Stabilization
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The first questions:
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What are the life-threatening
possibilities in this patient
Must I intervene immediately?
Assessing the patient's appearance
and vital signs
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Tension Pneumothorax
Diagnostic Approach
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80% to 90% of information pertinent to
the differential diagnosis is obtained by
the history, physical examination and
ECG.
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History
Physical Examination
Ancillary Studies
History
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A useful initial approach is to classify
patients into three categories:
Chest wall pain
 Pleuritic or respiratory chest pain
 Visceral chest pain
Pain, Associated syncope/near-syncope,
Associated dyspnea, Associated
hemoptysis, nausea and vomiting
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Differential Diagnosis
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Cardiac :
Angina
unstable angina
Acute MI
Pericarditis
vascular:
Aortic Dissection
Pulmonary Embolism
pulmonary hypertension
pulmonary:
Pleuritis and/or pneumonia
Tracheobronchitis
Spontaneous pneuomothorax
GI:
Esophageal reflux
Peptic ulcer
Gallbladder disease
Pancreatitis
Musculoskeletal: Costochondritis
Cervical disc disease
Infectious:
Herpes Zoster
Psychological:
Panic Disorder
Ancillary Studies
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Chest radiograph and
12-lead ECG
ECG should be
performed in all
patients 30 years old
and older within 10
min of arrival
Ancillary Studies; Serum Markers
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CK-MB values in
healthy controls
may be up to 5m/L
and up to 5% of
total CK.
Approach to Low Probability of Ischemia
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History alone is
not adequate to
exclude the
presence of
acute ischemia
The goal should
always be "zero
tolerance" for
missed AMI.
Approach to Low Probability of Ischemia
Approach to Low Probability of Ischemia
Initial assessment of critical
diagnoses