Approach to Chest Pain：胸部疼痛的方法.ppt

Approach to Chest Pain,Intern Bootcamp, 2014 Nathan Stehouwer, MD PGY-4, Internal Medicine & Pediatrics,Differential,Cardiac MI Pericarditis Myocarditis Aortic Stenosis Pulmonary PE PNA Asthma/COPD Acute Chest Syndrome Pleura Pleuritis Pneumothorax Aorta Dissection Perforated ulcer Chest wall Costocondiritis/musculoskeletal Esophagus Esophageal Spasm Eosinophilic Esophagitis Esophageal Rupture/Perforation GERD Mediastinitis RUQ pathology Panic attack,,,Pearl: ALWAYS have the patient point to the pain!,Typical vs. Atypical Chest Pain,Typical,Characterized as discomfort/pressure rather than pain Time duration >2 mins Provoked by activity/exercise Radiation (i.e. arms, jaw) Does not change with respiration/position Associated with diaphoresis/nausea Relieved by rest/nitroglycerin,Atypical,Pain that can be localized with one finger Constant pain lasting for days Fleeting pains lasting for a few seconds Pain reproduced by movement/palpation,Typical vs. Atypical Chest Pain,,UpToDate 2012,Typical vs. Atypical Chest Pain,,Cayley 2005,Case 1,You are the orphan intern on Wearn team at 6PM. You are called by the nurse because Ms. Z has developed chest pain. Ms. Z is a 62 yo F with PMHx of CAD s/p remote PCI to the LAD, COPD and right THA 3 weeks ago who was admitted for a COPD exacerbation. What would you do next?,Evaluation of Chest Pain,Case 1: Ask nurse for most current set of vital signs Ask nurse to get an EKG Obtain the admission EKG from the paper chart Go see the patient!,Evaluation of Chest Pain,Once at bedside, determine if patient is stable or unstable Perform focused history and physical exam Read and interpret the EKG. Compare EKG to old EKG if available If patient looks unstable or has concerning EKG findings, call your senior resident for help Write a clinical event note!,Evaluation of Chest Pain,focused physical exam for chest pain Vital Signs: tachycardia, hypertension/hypotension or hypoxia General: Sick appearing, actively having chest pain HEENT: JVD, carotid bruits Chest: Rales, wheezes or decreased breath sounds CVS: New murmurs, reproducible chest pain, s3 gallop Abd: Abdominal tenderness, pulsatile mass Ext: Edema, peripheral pulses Skin: Rash on chest wall,Case 1,You go see the patient. She had been feeling better after getting duonebs, but suddenly developed chest pain that is L-sided, 8/10 and worse with breathing. This pain is not like her prior MI. Vital signs: Afebrile, HR 120, BP 110/70, RR 28, O2 sat 89% on 2L (was 95% on RA this morning) Physical exam Gen – in distress, using accessory muscles of respiration Lungs – CTAB, no rales/wheezes Heart – tachycardic, nl s1, loud s2, no mumurs Abd – soft, NT/ND, active BS Ext – b/l LEs warm and well perfused Labs: CBC wnl, RFP wnl, BNP = 520, D-dimer = positive, Troponin = 0.12,Case 1,Case 1,Differential,Cardiac MI Pericarditis Myocarditis Pulmonary PE PNA Asthma/COPD Acute Chest Syndrome Pleura Pleuritis Pneumothorax Aorta Dissection Perforated ulcer Chest wall Costocondiritis/musculoskeletal Esophagus Esophageal Spasm Eosinophilic Esophagitis Esophageal Rupture/Perforation GERD Mediastinitis RUQ pathology Panic attack,Modified Wells Criteria,Clinical symptoms of DVT (3 points) Other diagnoses less likely than PE (1 point) Heart Rate >100 (1.5 points) Immobilization >/= 3 days or surgery within 4 weeks (1.5 points) Previous DVT/PE (1.5 points) Hemoptysis (1 point) Malignancy (1 point)Interpretation: >6: high 2-6: moderate <2: low,Next moves,DDIMER: 95% sensitive, VERY nonspecific ABG – Elevated A-a gradient fairly sensitive, highly nonspecific EKG – most commonly nonspecific changes (ST/T wave changes, etc) V/Q scan – helpful in patients with HIGH or LOW pretest probabilities in whom a CTPE cannot be obtained (eg CKD) LE Ultrasound: not sensitive CTPE Sensitivity 83% Specificity 96% Moderate - high clinical probability and positive CTPE: 92-96% chance of PE,Pearl,A CT angiogram (important for evaluating for Pulmonary Embolism or Aortic Dissection) requires EITHER:1) At least a 20G peripheral IVOR2) A Power injectable central line,Case 1,Diagnostic approach is simple if you suspect PE…,Probability low: obtain D-DIMER If positive: obtain CTPE If negative: PE excluded Probability moderate or high: obtain CTPE If positive: treat If negative: PE excluded,Acute Pulmonary Embolism,Stabliize patient oxygen Fluids if hypotensive! Anticoagulants Preferred: LMWH or Fondaparinux Enoxaparin 1.5mg/kg daily or 1mg/kg BID Fondaparinux subcutaneous once daily (weight based) Alternative: UFH (IV or SC) – select high intensity protocol Hemodynamically unstable patients High risk of bleeding (reversible) GFR < 30 Can initiate warfarin on same day IVC filter an alternative in patients with mod-high bleeding risk,Management,Search “heparin infusion orders”,,Pearl: If you have a moderate or high suspicion of PE, you can start anticoagulation while awaiting full diagnostic workup,PE with hypotension,Thrombolysis Administer over short infusion time Catheter based thrombectomy For failure of thrombolysis or likelihood of shock/death before thrombolysis can take effect (hours) Surgical thrombectomy Failure of above therapies,。