Chest Pain

What is the first step in initial assessment and triage in emergency medicine?

Restore Vital Functions, including ensuring clear airway, adequate breathing, and maintained circulation.

Why is an ECG critical in emergency medicine?

An ECG is critical to rapidly identify or exclude acute coronary syndromes, particularly ST-elevation myocardial infarction (STEMI), and can provide clues to other conditions like pericarditis or aortic dissection.

What can quick identification of pain onset and characteristics guide in history taking?

Urgency and next steps.

What might pain radiating to the back suggest during history taking?

Aortic dissection.

What might pain triggered by eating suggest during history taking?

Gastrointestinal issues.

How can knowing a patient's previous history and risk factors help in history taking?

It can focus the diagnosis.

What are cardiac markers used for in laboratory tests?

In laboratory tests, cardiac markers are used to diagnose and monitor heart conditions such as heart attacks. They help in assessing heart muscle damage by measuring levels of specific proteins released into the blood.

• Cardiac markers used in laboratory tests to diagnose and monitor heart conditions include troponin, creatine kinase (CK-MB), and myoglobin.

How is D-dimer helpful in laboratory tests?

D-dimer is helpful in laboratory tests for diagnosing blood clotting disorders, such as deep vein thrombosis and pulmonary embolism. It is a marker for fibrinolysis and clot formation.

What can blood count, ESR, and CRP indicate in laboratory tests?

• Blood count: Provides information on red blood cells, white blood cells, and platelets.

• ESR (Erythrocyte Sedimentation Rate): Indicates inflammation in the body.

• CRP (C-Reactive Protein): Shows presence of inflammation or infection.

In what condition is BNP elevated according to laboratory tests?

BNP is elevated in heart failure according to laboratory tests.

Why are pancreatic enzymes tested in laboratory tests?

Pancreatic enzymes are tested in laboratory tests to assess pancreatic function, diagnose conditions like pancreatitis or pancreatic insufficiency, and monitor treatment effectiveness.

When are cultures typically ordered in laboratory tests?

Cultures are typically ordered in laboratory tests when there is suspicion of infection or to identify specific pathogens causing an illness.

What can a chest X-ray help identify?

Pneumothorax, heart failure, or other structural abnormalities.

What is CT angiography essential for diagnosing?

Pulmonary embolism or aortic dissection.

When is echocardiography useful?

In assessing cardiac function and structures, particularly in suspected cases of cardiac tamponade or if valvular disease is suspected.

Cardiac Tamponade: Cardiac tamponade is a medical emergency where fluid accumulates in the pericardial sac, compressing the heart and impairing its function. Symptoms include low blood pressure, shortness of breath, and chest pain. Treatment involves draining the fluid to relieve pressure on the heart.

What is the importance of reevaluation and monitoring in patient care?

• Reevaluation and monitoring in patient care help assess treatment effectiveness, adjust interventions, detect complications early, and improve patient outcomes.

Why is it necessary to reassess after interventions in patient care?

Reassessment after interventions in patient care is necessary to evaluate the effectiveness of the treatment, monitor the patient's condition for any changes or complications, and adjust the care plan accordingly to ensure optimal outcomes and recovery.

What are some risk factors commonly associated with Acute Coronary Syndrome (ACS)?

Smoking, diabetes, hypertension, or hyperlipidemia.

Acute Coronary Syndrome (ACS) is a term used to describe a range of conditions associated with sudden, reduced blood flow to the heart. It includes unstable angina and heart attacks (myocardial infarctions).

What might an ECG show in a patient with suspected Acute Coronary Syndrome (ACS)?

ST/T changes.

• An ECG in a patient with suspected ACS may show ST-segment elevation or depression, T-wave changes, or Q waves indicative of myocardial ischemia or infarction.

What history might lead to suspicion of Pulmonary Embolism (PE)?

History of immobilization or DVT.

Pulmonary Embolism (PE) is a blockage in one of the pulmonary arteries in your lungs. It's usually caused by blood clots that travel to your lungs from your legs or other parts of your body. PE can be life-threatening and requires immediate medical attention.

What ECG pattern may be seen in a patient suspected of having Pulmonary Embolism (PE)?

S1Q3T3 pattern.

• S1Q3T3 pattern: This ECG pattern, characterized by S wave in lead I, Q wave in lead III, and inverted T wave in lead III, may be seen in patients suspected of having Pulmonary Embolism (PE).

How might Aortic Dissection present symptomatically?

With a tearing sensation and a history of hypertension.

Aortic Dissection: Aortic dissection is a serious condition where a tear occurs in the inner layer of the aorta, leading to blood flowing between the layers of the aortic wall, potentially causing life-threatening complications.

What imaging finding may be present in Aortic Dissection?

Widened mediastinum.

• Imaging findings in Aortic Dissection: Widened mediastinum, intimal flap, false lumen, and aortic wall thickening are common findings in aortic dissection.

What symptoms are associated with Pneumothorax?

Sharp, pleuritic pain.

Pneumothorax is a condition where air collects in the pleural space, causing lung collapse. It can be spontaneous, traumatic, or iatrogenic.

What physical examination findings might be present in a patient with Pneumothorax?

Diminished breath sounds and hyperresonance on the affected side.

• Hyperresonance in pneumothorax occurs due to the presence of air in the pleural space, causing increased resonance on percussion.

What are the diagnostic steps suggested for suspected ACS?

• ECG: to look for ST-segment changes

• Cardiac enzymes: troponin levels

• Chest X-ray: to rule out other causes

• Echocardiogram: assess heart function

• Angiography: to visualize coronary arteries.

What diagnostic tests are recommended for suspected PE?

• Diagnostic tests for suspected PE:

  1. D-dimer test: To rule out PE if low probability.

  2. CT pulmonary angiography (CTPA): Gold standard for diagnosis.

  3. Ventilation-perfusion (V/Q) scan: Alternative for patients with contraindications to CTPA.

How is aortic dissection diagnosed based on the patient's stability?

• Aortic dissection is diagnosed based on imaging tests like CT scan or MRI, not patient stability. Stability helps determine urgency of treatment.

When is further diagnostic work-up for pneumothorax considered necessary?

Further diagnostic work-up for pneumothorax is considered necessary when clinical suspicion remains high despite a negative initial imaging study or when the patient's condition deteriorates.

What are some cardiovascular causes of acute chest pain?

• Acute myocardial infarction

• Unstable angina

• Aortic dissection

• Pericarditis

• Pulmonary embolism

Why is it important to rapidly intervene in cases of pulmonary causes of acute chest pain?

Rapid intervention in pulmonary causes of acute chest pain is crucial to prevent life-threatening complications like pulmonary embolism or pneumothorax.

How are chest wall causes of acute chest pain typically identified?

• Chest wall causes of acute chest pain are typically identified through physical examination, medical history, and imaging tests like X-rays or CT scans.

• Some chest wall causes of acute chest pain include muscle strain, rib fractures, costochondritis, and inflammation of the cartilage connecting the ribs to the breastbone.

Why is it crucial to manage gastrointestinal causes of acute chest pain like pancreatitis promptly?

It is crucial to manage gastrointestinal causes of acute chest pain like pancreatitis promptly because delayed treatment can lead to serious complications such as organ damage, sepsis, and even death.

What is the significance of recognizing and addressing psychiatric causes of acute chest pain?

Recognizing and addressing psychiatric causes of acute chest pain is crucial to provide appropriate mental health support, prevent unnecessary medical interventions, and improve overall patient care and outcomes.

What are some cardiovascular causes of chronic chest pain?

Conditions that often require long-term management and can lead to acute exacerbations.

• Cardiovascular causes of chronic chest pain include angina pectoris, myocardial infarction, pericarditis, aortic dissection, and coronary artery disease.

How should chronic pain conditions related to the chest wall be managed?

They require a multidisciplinary approach for effective management.

What are some gastrointestinal causes of chronic chest pain?

Reflux oesophagitis and peptic ulcer disease, which often respond to medical therapy and lifestyle adjustments.

What interventions may be needed for pulmonary causes of chronic chest pain?

Chronic pleural effusion and tumors may need interventions and careful monitoring.

What are the symptoms of STEMI?

The chest pain is often described as heavy or like a squeezing sensation, typically radiating to the left arm, shoulder, jaw, or back. Accompanying symptoms, such as nausea, vomiting, dyspnea, and syncope, can provide important clinical context.

What ECG findings are characteristic of STEMI?

Characteristic ST-elevations along with pathological Q-waves and T-wave inversions that develop over time as the infarction evolves.

How can elevated cardiac troponins help in diagnosing STEMI?

Elevated cardiac troponins are indicative of myocardial injury.

Elevated cardiac troponins indicate heart muscle damage, aiding in diagnosing STEMI by confirming myocardial injury, supporting the diagnosis of a heart attack.

What imaging technique can visualize wall motion abnormalities in STEMI?

Echocardiography.

Echocardiography is a diagnostic test that uses sound waves to create images of the heart's structure and function, helping to assess heart health and detect abnormalities.

What are the symptoms of NSTEMI/Unstable Angina?

Similar to STEMI but can vary in intensity and duration.

Symptoms of NSTEMI/Unstable Angina:

• Chest pain or discomfort

• Shortness of breath

• Nausea or vomiting

• Sweating

• Fatigue

• Dizziness or lightheadedness

What ECG findings are associated with NSTEMI/Unstable Angina?

ST-segment depressions or T-wave inversions without the ST elevation seen in STEMI.

How can Troponin levels help diagnose NSTEMI?

Elevated Troponin levels may indicate some degree of myocardial injury in NSTEMI.

What might echocardiography show in a patient with NSTEMI?

Regional wall motion abnormalities indicative of ischemia or infarction.

Echocardiography in a patient with NSTEMI may show regional wall motion abnormalities, left ventricular dysfunction, and possible structural heart abnormalities.

What are the symptoms of aortic dissection?

The pain is severe, sudden, and described as tearing or ripping, often in the chest or abdomen, and may radiate to the back.

What physical findings may indicate aortic dissection?

Differences in blood pressure between limbs, a pulse deficit, or a new diastolic murmur if aortic regurgitation is present.

• Pulse deficits

• Blood pressure differences between arms

• Murmurs

• Neurological deficits

• Signs of shock

• Chest or back pain

• Syncope

• Aortic regurgitation

• Tamponade

• Ischemia

Is the ECG a definitive diagnostic tool for aortic dissection?

No, the ECG findings are often non-specific, but ischemic patterns may be present if the coronary arteries are involved.

How is aortic dissection definitively diagnosed?

CT angiography or transesophageal echocardiography (TEE) are often used for a definitive diagnosis, visualizing the dissection flap and aortic involvement.

• CT Angiography: Imaging technique using X-rays to visualize blood vessels.

• Transesophageal Echocardiography (TEE): Ultrasound method to examine heart structures via the esophagus.

Why is it important to rapidly differentiate among STEMI, NSTEMI/unstable angina, and aortic dissection?

• Rapid differentiation is crucial as each condition requires specific management strategies for optimal patient outcomes.

• STEMI requires immediate reperfusion therapy, NSTEMI/unstable angina needs risk stratification, and aortic dissection demands urgent surgical intervention.

What is a key clinical finding in Cardiac Tamponade that is particularly suggestive of the condition?

Pulsus paradoxus (a drop in blood pressure during inspiration of more than 10 mm Hg)

• Key clinical finding in Cardiac Tamponade: Beck's triad, which includes hypotension, distended neck veins, and muffled heart sounds, is particularly suggestive of the condition.

How do the ECG changes in Cardiac Tamponade occur?

The changes are a result of the fluid in the pericardial space dampening the electrical signals.

ECG changes in Cardiac Tamponade: ECG may show low voltage QRS complexes, electrical alternans, and tachycardia due to compression of the heart by pericardial fluid.

What imaging modality is crucial for diagnosing Cardiac Tamponade by showing effusion and chamber collapse?

Echocardiography is crucial for diagnosing Cardiac Tamponade by showing effusion and chamber collapse.

What are important diagnostic clues for pericarditis?

Pain characteristics and relief with positional changes.

• Pericarditis Diagnostic Clues:

  • Sharp, pleuritic chest pain

  • Pericardial friction rub

  • ECG changes (ST elevation)

  • Pericardial effusion on imaging

What is pathognomonic for pericarditis if present?

Pericardial friction rub.

A pericardial friction rub is a scraping or grating sound heard on auscultation of the heart, caused by the inflamed pericardial layers rubbing against each other during the cardiac cycle.

How do ECG findings in pericarditis differ from ischemic chest pain?

Diffuse rather than localized.

• Pericarditis ECG Findings:

  • Diffuse ST elevation with PR depression.

• Ischemic Chest Pain ECG Findings:

  • Localized ST elevation or depression.

What supports the diagnosis of pericarditis in terms of inflammatory markers?

Increased inflammatory markers.

What imaging technique may reveal an effusion in pericarditis?

Echocardiogram.

What are the typical symptoms of Heart Failure Exacerbation?

• Shortness of breath

• Fatigue

• Swelling in legs/abdomen

• Rapid weight gain

• Persistent cough

• Increased heart rate

• Confusion or impaired thinking

What is the hallmark laboratory finding indicating heart strain in Heart Failure Exacerbation?

BNP (B-type natriuretic peptide) is the hallmark laboratory finding indicating heart strain in Heart Failure Exacerbation.

Which imaging techniques are used to evaluate Heart Failure Exacerbation?

• Echocardiography: Evaluates heart function and structure.

• Chest X-ray: Shows heart size and signs of congestion.

• Cardiac MRI: Provides detailed images of heart structure and function.

• CT angiography: Visualizes coronary arteries and heart anatomy.

What is Takotsubo Cardiomyopathy often triggered by?

Acute emotional or physical stress

Takotsubo Cardiomyopathy is a temporary heart condition where the heart muscle weakens, often triggered by extreme emotional or physical stress. It is also known as "broken heart syndrome" due to its association with stressful events.

How does the presentation of Takotsubo Cardiomyopathy mimic that of an acute MI?

It can mimic that of an acute MI

Takotsubo Cardiomyopathy, also known as "broken heart syndrome," mimics acute MI with symptoms like chest pain, shortness of breath, and ECG changes, making it challenging to differentiate initially.

What is a key difference between Takotsubo Cardiomyopathy and an MI in terms of coronary angiography?

Coronary angiography usually does not show significant blockages in Takotsubo Cardiomyopathy

What does the echocardiogram reveal in Takotsubo Cardiomyopathy?

The characteristic apical ballooning with hypokinesis in the absence of obstructive coronary artery disease

The echocardiogram in Takotsubo Cardiomyopathy reveals transient left ventricular dysfunction with apical ballooning and hypercontractility of the basal segments.

What is a key characteristic of Takotsubo Cardiomyopathy presentation?

Key characteristic of Takotsubo Cardiomyopathy presentation: Takotsubo Cardiomyopathy typically presents with sudden and severe chest pain, often triggered by emotional or physical stress, resembling a heart attack.

How does coronary angiography typically differ in Takotsubo Cardiomyopathy compared to an acute MI?

In Takotsubo Cardiomyopathy, coronary angiography shows no significant blockages, unlike acute MI where blockages are typically present.

What is a characteristic finding on echocardiogram in Takotsubo Cardiomyopathy?

• Apical ballooning or "apical ballooning syndrome" is a characteristic finding on echocardiogram in Takotsubo Cardiomyopathy.

What is a key feature of Gastroesophageal Reflux Disease (GERD) pain?

• One key feature of Gastroesophageal Reflux Disease (GERD) pain is a burning sensation in the chest, often referred to as heartburn.

How can Gastroesophageal Reflux Disease (GERD) be confirmed?

Gastroesophageal Reflux Disease (GERD) can be confirmed through tests like upper endoscopy, esophageal pH monitoring, and esophageal manometry.

What is Esophageal Perforation (Boerhaave Syndrome) characterized by?

Severe pain, typically following episodes of forceful vomiting.

Esophageal Perforation (Boerhaave Syndrome):

Esophageal perforation, also known as Boerhaave syndrome, is a life-threatening condition where there is a rupture in the esophagus, usually caused by forceful vomiting or retching. This leads to leakage of contents into the chest cavity, causing severe chest pain, difficulty swallowing, and potentially fatal complications. Immediate medical attention is crucial for diagnosis and treatment.

How can the presence of air in the soft tissues of the chest (mediastinal crepitus) be a key sign of Esophageal Perforation (Boerhaave Syndrome)?

It can be a key sign of the condition.

Air in the soft tissues of the chest (mediastinal crepitus) can be a key sign of Esophageal Perforation (Boerhaave Syndrome) due to the leakage of air from the perforated esophagus into the mediastinum, causing subcutaneous emphysema and crepitus upon palpation.

What are common symptoms of peptic ulcer disease?

Episodic ulcer pain related to meals.

What is a common contributing factor to peptic ulcer disease?

NSAID use.

What are some diagnostic tests for peptic ulcer disease?

Upper endoscopy and testing for H. pylori.

What is Takotsubo Cardiomyopathy often triggered by?

Acute emotional or physical stress

How does the presentation of Takotsubo Cardiomyopathy mimic that of an acute MI?

It can mimic that of an acute MI

What does coronary angiography usually show in Takotsubo Cardiomyopathy?

Usually does not show significant blockages

What is revealed in the echocardiogram of Takotsubo Cardiomyopathy?

Characteristic apical ballooning with hypokinesis in the absence of obstructive coronary artery disease

What is a key feature of Gastroesophageal Reflux Disease (GERD) pain?

Burning sensation

How is GERD pain usually worsened?

Worsened by lying down or after meals

How can GERD be confirmed?

Upper endoscopy or 24-hour pH monitoring

What type of pain does Acute Pancreatitis present with?

Severe, steady pain in the upper abdomen

Where does the pain from Acute Pancreatitis often radiate to?

Often radiating to the back

How is Acute Pancreatitis diagnosed?

Elevated pancreatic enzymes (lipase and amylase) in the blood

What can imaging like CT scans show in Acute Pancreatitis?

Pancreatic inflammation and complications

What is Takotsubo Cardiomyopathy often triggered by?

Acute emotional or physical stress

How does the presentation of Takotsubo Cardiomyopathy mimic that of an acute MI?

The presentation can mimic that of an acute MI

What does coronary angiography usually show in Takotsubo Cardiomyopathy?

Usually does not show significant blockages

What does the echocardiogram reveal in Takotsubo Cardiomyopathy?

Apical ballooning with hypokinesis in the absence of obstructive coronary artery disease

What is the characteristic feature seen in the echocardiogram of Takotsubo Cardiomyopathy?

Apical ballooning with hypokinesis

What are typical symptoms of Pulmonary Embolism (PE)?

Sudden pleuritic chest pain and shortness of breath

How can the diagnosis of PE be supported?

Risk factors or signs of deep vein thrombosis (DVT)

What laboratory findings can indicate PE?

Elevation in D-dimer, troponins, and BNP due to right ventricular strain

What is the definitive imaging for PE?

CT pulmonary angiography

What alternative imaging can be used for PE when CT is contraindicated?

V/Q scan

What are common symptoms of pneumothorax?

Sharp pain and acute shortness of breath.

How can pneumothorax be diagnosed through physical examination?

Decreased breath sounds and hyperresonance.

How is the diagnosis of pneumothorax confirmed with imaging?

Chest X-ray shows a visible pleural line and lack of lung markings.