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chest pain نسيبة الزبيري....pptxhddsgghhh
- 1. Chest pain Done by:Nosiba Abd ulraof Alzobiry Supervisor: Dr/Mokhtar Alnahary
- 2. Introduction:- *Chest pain isamong the most common reasons for which patients present for medical attention at either an emergency department (ED) or an outpatient clinic. *It is helpful to frame the initial diagnostic assessment and triage of patients with acute chest discomfort around three catagories: (1) myocardial ischemia. (2) other cardiopulmonary causes (myopericardial disease, aortic emergencies, and pulmonary conditions) (3) non cardiopulmonary causes. *Fewer than 15% of evaluated patients are eventually diagnosed with acute coronary syndrome (ACS) . *The most common diagnoses are gastrointestinal causes(42%)
- 3. *Score 0-3: 2.5%MACE over next 6 weeks Discharge Home → *Score 4-6: 20.3% MACE over next 6 weeks Admit for Clinical Observation *Score 7-10: 72.7% MACE over next 6 weeks Early Invasive Strategies →
- 4. The EDACS Score(Emergency Department Assessment of Chest Pain Score) • is a clinical tool used to assess the risk of acute coronary syndrome (ACS) in patients presenting with chest pain. It helps emergency department (ED) physicians make decisions about which patients can be safely discharged and which ones need further testing or admission. The Vancouver Chest Pain Rule** • is a clinical decision tool designed to help emergency department (ED) physicians determine which patients presenting with chest pain are at low risk for acute coronary syndrome (ACS) and can be safely discharged without further cardiac testing. This rule aims to reduce unnecessary admissions and testing, streamlining care for patients with chest pain.
- 5. What are thesources of the chest pain(anatomic locations): .The chest wall including the ribs,the muscles and the skin. .The back including the spine,the nerves and the back muscles. . The lung,the pleura and the trachea . .The heart and the pericardium. .The aorta, the esophagus and the diaphragm. .Referred pain from the abdominal cavity .
- 6. Causes of chestpain Nontrumatic cardiopulmonary Non cardiopulmonary trumatic
- 7. cardiopulmonar y 1-Myocardial ischemia (Angina) 2-Myocardial infarction. 3-Pericarditis 4-cardiac temponade 5-Aortic stenosis 6-Mitralvalve prolapse. 7-Hypertrophic cardiomyopathy. 8-Broken heart syndrome. 1-Pneumonia or pleuritis 2-Pneumothorax <tension ptx> 3-Malignancy 1-Aortic dissection 2-Pulmonary embolism 3-Pulmonary hypertension cardiac vascul ar pulmonar y
- 8. Non cardiopulmonary causes 1-emotional or psychiatric 2-disorderof the breast 1-costochondritis 2-herpes zoster 3-epidemic myalgia(bornholm disease) 4-cervical disc pain 1-gastroesophegeal reflux disease 3-esophegeal spasm 2-peptic ulcer 4-esophegeal perforation (Boerhaave syndrome) 5-Mallory Weiss syndrome 6-gall bladder disease(gall bladder stone or cholecystitis) 7-pancreatitis Gastrointest inal Neuromusc ular Others
- 9. stable angina andacute coronary syndrome
- 10. Myocardial infarction:- Clinical manifestation:- -Acuteretrosternal chest pain: Typical: dull, squeezing pressure and/or tightness, Commonly radiates to left chest, arm, shoulder, neck, jaw, and/or epigastrium. -Precipitated by exertion or stress. Physical examination:- -Patient is restless,anxious,pallor, B.p and H.R may be normal or mildly raised -(Levine’s sign) -Sign of complication.
- 11. ECG(STEMI) Acute stage: (myocardialischemia) Hyperacute T waves (peaked T wave) ST elevations in two contiguous leads Intermediate stage: (myocardial necrosis present) Absence of R wave,T-wave inversions,Pathological Q waves Chronic stage: permanent scarring Persistent, broad, and deep Q waves Often incomplete recovery of R waves Cardiac biomarkers:- 1-CardiacTroponin T/I which start Rise in 3-8 hour ,reach to maximum 12–24 hours last for 7-10 days(cTnT can last for 14 days) 2-CK-MB:start Rise 4–9 hours, reach to maximum12–24 hours, last ∼ for2–3 days. 3-Myoglobin:start Rise 1 hour,reach to maximum 4–12 hours, last ∼ for24 hours Echocardiography Coronary angiography
- 13. MANAGEMENT: 1-Analgesia: Morphin 5-10mg(I.V) 2-Dual antiplatelettherapy (DAPT): Aspirin 150-300mg and Clopodogrel 300-600mg as loading dose then 75mg/day 3-Thrombolytic therapy: (Use if patients have no contraindications) Should be given as early as possible a-streptokinase 1.5million units in 100ml saline I.V or b-Human tissue plasminogen activator(t PA)-Alteplase (relative selectivity and not antigenic but very expensive) 4-Coronary Angioplasty: used in case of:- *patient arrived early Contraindication to Thrombolytic therapy
- 14. 5-Anticoagulants Low molecular weightheparin or Unfractionated heparin 6-B-adrenoceptor antagonists (if there is no contraindications) Initiate within 24 hours. Oral: all patients without contraindications IV: continuing hypertension, refractory ischemic pain 7-Nitrate 8-Oxygen 9-Statins:All STEMI/NSTEMI patients, regardless of baseline cholesterol.
- 15. Pericarditis:- Clinical feature:- -Symptoms:- Chest pain,characteristically sharp, retrosternal,pleuritic related to respiration & positional relieved by leaning forward. • Fever and palpitations are common. -Sign:- Tachycardia Palpation:- Apex beat may be impalpable. Auscultation:-Muffled heat sound due to pericardial effusion. coarse pericardial fraction rub which loudest in patient sitting forward. Investigations:- -ECG:- Stage 1: diffuse ST elevations, ST depression in aVR and V1, PR segment depression . Stage 2: ST segment normalizes in 1 week. ∼ Stage 3: inverted T waves. Stage 4: ECG returns to normal baseline after weeks to months .
- 16. -Imaging:- Chest x-ray .Echocardiography . Cardiac MR CT scan with IV contrast management: 1.often self-limited over 3-10days 2.NSAIDs can alleviate symptoms and prevent a recurrence. 3-Supportive therapy(treatment of the underlying causes)
- 18. Aortic dissection: Risk factorsor Etiologies: -Hypertension -Trauma, e.g( deceleration injury or iatrogenic injury during valve replacements or graft surgery) -Vasculitis with aortic involvement as syphilis .Atherosclerosis -Congenital as Connective tissue disease (Marfan syndrome) Bicuspid aortic valve (e.g., in Turner syndrome) -Coarctation of the aorta -Third-trimester pregnancy Manifestation: Sudden and severe tearing/ripping pain often radiating to the back between shoulder blades Syncope, diaphoresis, confusion, or agitation Hypertension or hypotension Asymmetrical blood pressure and pulse readings between limbs
- 19. Investigation: -ECG Normal findings Signs ofleft ventricular hypertrophy Nonspecific changes, such as ST depression and T-wave changes -Laboratory studies D-dimer: elevated levels -Chest x-ray Often normal but may show Widened mediastinum Alteration of the mediastinal contour seen on serial imaging Mediastinal mass -Transesophageal echocardiography Investigations of choice are( CT or MR angiography) Management: Initial management pain control and antihypertensive treatment Stanford A dissection: immediate surgery. Stanford B dissection: treat conservatively Supportive care
- 20. Pulmonary embolism Risk factor:- -InPMH:- H/O Trauma, fracture, surgery. *H/O prolonged immobility. *H/O previous DVT *Drug history (hormonal therapy or OCP). *H/o malignancy -Social H/o:-Smoking. -Family:- FH +ve. Clinical features:- -Sudden onset dyspnea is the most common symptom -Pleuritic chest pain(Acute, sharp retrosternal pain caused by inflammation of the parietal pleura Typically aggravated by coughing, swallowing, or deep inspiration) -Cough, Hemoptysis (occurs in 10-15% of pts.). -Syncope especially in massive pulmonary embolism. Non specific Signs:- -Tachypnea: the most common sign. -Tachycardia. -Low grade fever Chest exam usually normal
- 21. Investigation:- -CXR: - isfrequency normal but may show non-specific radiographic appearance as(Westermark's sign ,Hampton’s hump sign, Palla's sign) . Westermark's sign Palla's sign Hampton’s hump sign
- 22. The ECG isoften normal but may show Most frequent ECG change is T wave inversion in the anterior chest leads. *Sinus tachycardia • RAD (Right axis deviation) • RBBB (Right bundle branch block). * S1-Q3-T3 (deep S wave in lead I and deep Q wave and T wave inversion in lead III, This change is specific but not sensitive .
- 23. *Cardiac enzyme: The serumtroponin I may be elevated, reflecting right heart strain *Arterial blood gas (ABG): Often normal Common findings Hypoxemia (e.g., SaO2, PaO2 < 80 mm Hg) ↓ Respiratory alkalosis *D-dimer: if normal the PE is very unlikely or exclude in low risk pt. only. If positive not confirm(GOOD NEGATIVE) *VQ scan *CTPA(CT of the pulmonary arteries with intravenous contrast) is the first-line diagnostic test *Pulmonary-angiography (Gold standard) But done only if other test are equivocal (invasive)
- 25. Management: -Stabilize the pt.ABC. -Analgesia . -Anticoagulation: In pts. With suspected DVT or PE anticoagulant therapy (should be started immediately) -Thrombolytic are used only in Pts. with massive PE if contraindicated then inferior vena cava filter used.
- 27. Pneumothorax Clinical features:- -Sudden, severe,and/or stabbing, pleuritic chest pain + Dyspnea is the most-common presentation. General examination:- -(tachypnea, May cyanosis, pulses Paradoxus,decrease blood pressure). Chest examination:- -*Inspection: RR , decreased chest expansion in affected sid. *Palpation: decreased chest expansion in affected side +/- Mediastinal deviation,decreased ofTVF. *Percussion: Hyper-resonant on affected side. *Auscultation:Absent breath sounds on affected side, no added sound.
- 28. Investigation:- - CXR: isdiagnostic by showing black shadow (i.e., increased transparency), lung collapse Mediastinal deviation suggests the presence of tension Pneumothorax. -Ultrasonography or CT: are both superior to CXR for detection of small PTx. Management:- by needle chest decompression.
- 29. Pneumonia Clinical feature: Main complaintis fever , cough and pleuritic chest pain Sign: Increased RR ± tachycardia, hypotension. Chest examination:- Inspection :decreased in chest expansion of affected side. Palpation: decreased in chest expansion of affected side & No deviation. TVF is increased. Percussion: Dullness. Auscultation: decreased air entry , Crepitation’s +/- Rhonchi , +ve Egophony.
- 30. Investigation: *Chest x-ray (+vefinding) Consolidation in one or more lung lobe Bulging Fissure signe *CBC: Leukocytosis * ESR & CRP increased * Microbiological investigation 1.Sputum culture 2.Blood culture. Management: 1.Oxygen to maintain pao2>/60mm Hg and sao2>/=94% 2.I.V FLUID if there is dehydration 3.Analgesics and antipyretic 4.Antibiotics 5.Physiotherapy
- 31. Esophageal perforation:- Clinical feature:- -Macklertriad (esp. in Boerhaave syndrome) 1-Vomiting and/or retching. 2-Severe retrosternal pain that often radiates to the back . 3-Subcutaneous or mediastinal emphysema: crepitus in the suprasternal notch and neck region or crackling sound on chest auscultation (Hamman sign). -Dyspnea, tachypnea, tachycardia. -Dysphagia. -History of recent endoscopy. Investigation:- -Chest x-ray: Widened mediastinum. Pneumomediastinum, pneumothorax, pneumoperitoneum, subcutaneous emphysema . -Neck x-ray: subcutaneous emphysema.
- 32. Management :- *Initial management: 1-ABCDEsurvey. 2-Nothing by mouth (NPO). 3-IV proton pump inhibitor. 4-Broad-spectrum IV antibiotics. 5-Parenteral analgesia. *Nonsurgical treatment: Indications: Small, contained perforation, demonstrated by: Either a contained leak with the neck, within the mediastinum, or between the mediastinum and visceral lung pleura. *Surgical treatment: Indications: Hemodynamic instability. Patients who do not fulfill the criteria for conservative management . Clinical deterioration during conservative management. -Procedure: Closure of the ruptured esophageal segment.
- 33. Esophageal spasm:- Clinical feature:- -Chestpain in esophageal spasm: Non exertional,retrosternal, pressure, tightness or burning pain.may radiate to back,neck or arm(closely memic angina),prolonged last between minuet to hours,aggravated by eating quickly, hot or cold drinking, anxiety or depression, accompanied by heart burn or dysphagia, relieved by antacid. Investigation:- -Upper endoscopy: typically normal in hypermotility disorders -Esophageal barium swallow: Distal esophageal spasm: multiple nonperistaltic contractions, which resemble pseudodiverticula (corkscrew appearance; rosary bead esophagus -Manometry.
- 34. Management:- *symptomatic controlled:- 1.smooth musclerelaxant as nitrate or CCB. 2.analgsic. 3.consider PPI if GIRD is presented. *life style modification:- *invasive therapy:- 1.Endoscopic. 2.surgery.
- 35. Gastro esophageal reflux disease Pepticulcer Prolonged burning pain behind the sternum, radiating to the throat, aggravated after meal also on lying down in bed and relived by sitting up or with antacid Prolonged dull aching or burning epigastric and substernal pain may radiating to the back aggravated by eating if it is GU or by fasting if it is DU Relived by antacid ,by vomiting if it's GU or by eating if it's DU
- 36. Costochondritis Clinical features: Sharp, well-localizedpain that is reproducible on palpation of costal cartilage History of recent exercise/exertion/chest wall trauma Diagnostics: Clinical diagnosis CXR: normal Treatment: -Pain management -paracetamol -NSAIDs (e.g., naproxen, ibuprofen) -Physical therapy (i.e., stretching exercises) -Reduction of activities that provoke symptoms -Cough suppressants
- 37. Herpes zoster Clinical features Severeburning or throbbing pain Thoracic dermatomes are most commonly affected Maculopapular rash that develops into a vesicular rash in a dermatomal distribution Diagnostics -Clinical diagnosis -PCR of vesicle fluid positive for varicella-zoster virus DNA Treatment: Antiviral
- 38. Emotional or psychiatricchest pain Clinical features - -usually feel like a Retrosternal sharp, stabbing sensation that starts suddenly, even if a person is inactive.not radiated pain.more common in women -No associated esophageal symptoms (e.g., no heartburn, dysphagia) (*Diagnosis of exclusion) Treatment Reassure the patient. Referral to psychologist
- 41.