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2 cases of chest pain

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  • 1. Case #1 47 year old female with Chest Pain
  • 2. History
    • 47 year old Hispanic female presents with midsternal chest pain and sob for 1 hr.
    • Patient states she woke up with blue fingers and lips.
    • She also c/o right occipital head ache for 1 day, pulsating in nature.
    • States she is “having difficulty talking” and is having dizziness. States she “feels off-balance”. Also states blurry vision.
    • Patient also c/o lower abdominal pain with burning when she urinates and also urgency
  • 3. History
    • Past Med Hx: None
    • Past Surg Hx: None
    • Social Hx: No tob, etoh or drugs
    • Family Hx: no related hx
    • Allergies: NKDA
    • Medications: Tylenol
  • 4. History
    • ROS:
      • SOB, CP, palpitations, nausea, dysuria, urgency, HA, dizziness
    • VS 97.5 93 20 118/73 88% on RA
  • 5. Physical
    • General: well developed, alert, no distress, nontoxic
    • EENT: lids, conjunctiva nl, PERRL and EOMI, hearing grossly intact, lips, teeth, gums, palate nl, oropharynx nl
    • Resp: resp effort nl, clear to auscultation
    • CV: RRR, no murnurs, radial pulse nl
    • GI: no tenderness or mass, BS +, nondistended, no rebounding
  • 6. Physical
    • Musc: ALL extremities nl, gait nl
    • Neck: supple, symmetric, no masses, thyroid nl, no JVD
    • Skin- palpation nl, well hydrated, cyanotic fingers
    • Neuro- sensory and motor grossly intact, GCS 15
  • 7. EKG
  • 8. CXR
  • 9. Labs
    • CBC
      • WBC- 11.3
      • Hg - 13.7
      • Hct - 39.2
      • Plat – 336
    • D-dimer 80
    • CHEM-7
    • Na- 138
    • K- 3.8
    • Cl- 103
    • CO2- 24
    • Bun- 10
    • Cr- 0.9
    • Glu- 113
  • 10. Labs
    • ABG
      • 7.41/34/175/21/-3/ on supplemental 02
      • Lact
      • Met Hb- 30.3%
  • 11. Assessment/Plan
    • Methemoglobinemia – unclear etiology
    • Methylene blue given
    • Complete resolution of symptoms
    • Admited to medicine. Dc ’d home the next day
  • 12. Methemoglobinemia Troy W. Pennington DO Attending Physician- ARMC
  • 13. Which of these Substances can cause Methemoglobinemia?
    • A. Hurricaine Spray
    • B. Nitroglycerin
    • C. Dapsone
    • D. Sulfa Antibotics
    • E. Pyridium
    • F. A & B
    • G. A & B & D
    • H. All of the above
  • 14. Nitroglycerin + Nitrates
    • Agents that inflict large oxidant stress on patients, including the following:
      • -Nitroglycerin -Chloroquine
      • -Nitrates -Dapsone
      • -Nitrities -Phenazopyridine
      • -Nitroprusside -Sulfonamides
      • -Amyl nitrite -Quinones
      • -Lidocaine -Phenacetin
      • -Benzocaine -Primaquine
      • -Prilocaine
  • 15. Some drugs associated with Methemoglobinemia
  • 16. Enviromental Agents Aniline dyes Aromatic amines Arsine Butyl nitrite Chlorates Chlorobenzene Chromates Combustion Products Nitroaniline Dimethyltoluidine Foods containing (nitrates / nitrites) Well water Naphthalene Silver nitrate Trinitrotoluene Nitrophenol Nitrobenzene
  • 17. Methemoglobinemia
    • Met-Hb is a form of hemoglobin that doesn ’t bind oxygen
    • When its concentration is elevated in red blood cells a functional anemia and tissue hypoxia occur
    • Normal met-Hb levels are <1%
  • 18. Methemoglobinemia
    • Red blood cells each contain 4 hemoglobin chains
    • Each hemoglobin molecule is composed of 4 polypeptide chains associated with 4 heme groups
  • 19. Methemoglobinemia What happens in metHb? The iron within hemoglobin is oxidized from the ferrous (Fe 2+ ) state to the ferric (Fe 3+ ) state, resulting in the inability to transport oxygen and carbon dioxide.
  • 20. *Most common*, enzyme deficiency in RBC ’s… Widespread deficiency of enzyme in multiple tissues, erythrocytes, liver, fibroblasts, and brain. Associated with severe CNS symptoms, MR, cyanosis and premature death… Hemopoietic system involved; platelets, RBC ’s, white cells only main consequence is cyanosis… Similar to type I, isolated erythrocyte involvement resulting in chronic cyanosis…
  • 21. Causes of Methemoglobinemia
    • Children (usually under 4 months) with underdeveloped protective mechanisms
    • Hereditary lack of protective cellular capabilities
      • NADH methemoglobin reductase deficiency
      • Hemoglobin M disease
      • Pyruvate kinase deficiency & impared glycolytic pathway resulting in deficient NADH production
      • G-6-PD deficiency (may have impared production of NADPH in the hexose-monophosphate shunt)
  • 22. Met-Hb…Concentrations Normal methemoglobin concentrations are 1% (range, 0-3%) 3-15%- slight discoloration (eg, pale, gray blue)
  • 23.
    • 15-20% likely asymptomatic, cyanosis likely
    • 25-50% Signs & Symptoms:
      • Headache
      • Dyspnea
      • Lightheadedness
      • Weakness
      • Confusion
      • Palpitations, chest pain
    Met-Hb…Concentrations
  • 24. 50-70% Altered mental status Delirium Death Met-Hb…Concentrations
  • 25. Differential Diagnosis varies with age
  • 26. Met-Hgb how do you make the diagnosis? -Diagnosis confirmed by direct measurement of methemoglobin by a multiple wavelength co-oximeter ABG- Normal PaO 2 Concentrations are usually found on analysis ** Clinical cyanosis is the presence of normal arterial oxygen tensions is highly suggestive of methemoglobinemia** The arterial oxygen tension is related to the amount of oxygen dissolved in blood plasma, not the much larger pool that is bound to hemoglobin…
  • 27. Met-Hb… Traps
    • Pulse oximetry is inaccurate in patients with high met-Hb levels
    • Pulse oximetry of patients with low-level methemoglobinemia often reveals falsely low values for O2 sat
    • Also falsely high in those with high-level methemoglobnemia
    • Met-Hb absorbs light at wavelengths that also absorb deoxyhemoglobin and oxyhemoglobin
  • 28. Pulse oximeter Pulse oximetry is a simple non-invasive method of monitoring the percentage of hemoglobin (Hb) which is saturated with oxygen. An oximeter detects hypoxia before the patient becomes clinically cyanosed. How does an oximeter work? A source of light originates from the probe at two wavelengths (660nm and 940nm). The light is partly absorbed by hemoglobin, by amounts which differ depending on whether it is saturated or desaturated with oxygen. By calculating the absorption at the two wavelengths the processor can compute the proportion of hemoglobin which is oxygenated . Pulse oximetry cannot distinguish between different forms of hemoglobin. Carboxy-hemoglobin (hemoglobin combined with carbon monoxide) is registered as 90% oxygenated hemoglobin and 10% desaturated hemoglobin - therefore the oximeter will overestimate the saturation. The presence of methemoglobin will prevent the oximeter working accurately and the readings will tend towards 85%, regardless of the true saturation. A CO-oximeter measures absorption at additional wavelengths to distinguish CO from O 2 and determines the blood oxygen saturation more reliably.
  • 29. Pulse oximeter Methemoglobin increases absorbtion of light at both wavelengths (more at 940nm) Met-Hb offers optical interference to the pulse oximetery by falsely absorbing light This leads to the plateau in the oxygen saturation at 85%. Co-oximetry is KEY
  • 30. Met-Hb making the case
    • Blood that is cyanotic in color due to cariopulmonary disease turns RED on exposure to oxygen…..
    • …………………… .Blood with met-Hb does not
    • Arterial blood is usually chocolate Brown
      • Simple bedside Tests:
    • Bubble 100% O 2 in tube with dark blood if it stays dark most likely because of met-Hb presence
  • 31. Met-Hb… making the case
    • Bedside Testing Continued:
    • Place 1-2 drops of blood on white filter paper, the evaluate for color change upon exposure to oxygen…
    • (blow supplemental O 2 onto the filter paper)…..
      • Deoxygenated hGb changes from
      • Dark Red …to … Violet …or Bright Red
      • Methemoglobin remains… BROWN
  • 32. metHb-Blood Looks Like Chocolate metHb oxygentated blood………….. blood
  • 33. The Fugate Family
  • 34.  
  • 35.  
  • 36. Jake & Ellwood
  • 37. Blue People get… Blue Drugs :)
    • Met-Hb Treatment:
    • Methylene Blue 1-2mg/kg IV
      • (generally up to 50 mg/dose in adults, adolescents, and older children) as a 1% solution over 5 minutes…
      • {Methylene blue increases the activity of NADH-methemoglobin reductase
      • in RBCs assisting in the conversion of the ferric (Fe 3+) to the ferrous (Fe2+) iron}
      • Generally levels <30% don ’t need treatment
      • May repeat in 1 hour up to 7mg/kg total
      • Methylene Blue is an oxidant itself at levels >7mg/kg
      • Contraindicated in G6PD deficiency can lead to severe hemolysis
      • Ascorbic acid (vitamin C) is an antioxidant that may also be administered in patients with levels of more than 30%
      • N-acetylcysteine has been shown in recent studies but is not yet an approved treatment
      • In severe cases exchange transfusion and hyperbaric oxygen have been described
      • Methylene blue has been given IO in infants
  • 38. Case #2 71 Year old female with Chest Pain
  • 39. 71 year old female -chest pain Intermittent yest. Constant now Today substernal chest pressure 9/10 since 9am today… PMH: none Meds: none Alg: none SH: negative Aunt Bee EKG ……….. : 0-
  • 40. 71 year old female -chest pain Intermittent yest. Constant now Today substernal chest pressure 9/10 since 9am today… PMH: none Meds: none Alg: none SH: negative
  • 41. That would be cheating, it didn ’t help anyway :)- Aunt Bee
  • 42. Aunt Bee That would be cheating, it didn ’t help anyway :)-
  • 43. Aunt Bee Mm-Mm-Good Your smarter than a computer ? :)-
  • 44. Aunt Bee That would be cheating, it didn ’t help anyway :)-
  • 45. Aunt Bee
  • 46. Aunt Bee Mm-Mm-Good That would be cheating, it didn ’t help anyway :)-
  • 47. ACC/AHA 2007-2008 Guidelines
    • Onset & Recognition of Symptoms
      • ACS need not present with CHEST PAIN
    • 1/3 of all MI ’s present with symptoms other than chest pain
    • Remember Anginal Equilvalents
      • Dyspnea
      • Extreme Fatigue
      • Diaphoresis
      • Syncope
  • 48. AHA / ACC Update 2008
    • Top Five Factors on initial History
      • Nature of anginal symptoms
      • Prior history of CAD
      • Male gender
      • Older age
      • Increasing number of traditional risk factors
        • HPI is the most important…risk factor profile or lack of risk factors has limited utility in the acute setting
  • 49. Clinical Characteristics of Angina Characteristic More likely to be angina Less likely to be angina Type of pain Dull, pressure Sharp, stabbing Duration 2 to 5 min, always <15–20 min Seconds or hours Onset Gradual Rapid Location Substernal Lateral chest wall, back Reproducible With exertion With inspiration Associated symptoms Present Absent Palpation of chest wall Not painful Painful, exactly reproduces pain complaint
  • 50. Initial Evaluation and Management Immediate Management
    • A 12-lead EKG within 10 minutes of arrival
      • For all patients with chest pain or anginal equilvalent
    • In Patients with a concerning story or questionable EKG, repeat EKG early…
      • Look for evolving changes
    • Consider obtaining leads V7-V9 with a good story & nondiagnostic initial EKG…
      • Helps identify posterior & right ventricular involvement and hard to find left circumflex lesions
  • 51. AHA / ACC Quick Facts
    • Response to Nitro and/or GI cocktail is neither sensitive nor specific
    • Up to 6% of NSTEMI ’s are associated with normal EKG’s
    • Unstable angina has a normal EKG up to 4% of the time
  • 52. EKG- Rules To Live By
    • Watch for reciprocal (mirror image) changes opposite
    • site of a suspected MI
    • Inferior MI with reciprocal changes in V1-V2, consider
    • posterior MI
    • Inferior MI with decreased B/P, decreased heart rate,
    • consider right-sided MI. This is especially true if ST
    • elevation is greater in lead III than lead II
    • About 30% of left inferior MI ’s are also right-sided MI’s
    • Right-sided MI ’s may need fluids before nitrates
  • 53. The Rodney Dangerfield Leads…..V7-V9
    • Approximately 4% of AMI patients have STE isolated in the posterior leads …..
    • Isolated posterior STEMI does qualify for emergent reperfusion therapy…
    “ I just don’t get any Respect ”
  • 54. The Posterior Leads V7-V9
    • Posterior chest leads (V7-V9)
    • - V7: Posterior axillary line, fifth intercostal space
    • - V8: Midscapular line, fifth intercostal space
    • - V9: Left of the vertebrae, fifth intercostal space
  • 55. Posterior MI
  • 56. Posterior MI with Posterior Leads
  • 57. Posterior Wall MI
    • Acute inferior/ lateral wall MI
    • Isolated posterior wall MI---rare
    • Increased R over V1-V3
    • R/S ratio > 1.0 over V1 or V2
    • Depressed ST segment and tall T over V1-V3
  • 58. Posterior Wall MI
    • Reverse nature
    • increased R----depressed Q
    • depressed ST ----elevated ST
    • high T----inverted T
    • ST depressed over V1-V3 --- ant wall ischemia or post wall MI
    • ST elevated > 1mm over V8 and V9
  • 59. Ischemic ST Elevations Non-Ischemic ST Elevations
  • 60. Outcome?
    • Acute Posterior Wall Mi
      • Went to cath lab
      • Had a 100% circumflex lesion
      • Pain immediately resolved upon opening and stenting the circ.
      • Did well went home without any further complications……….
  • 61. THANK YOU
    • Questions?
    • You can contact me at:
    • [email_address]

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