CHEST PAIN MANAGEMENT
ACS
• Any condition brought on by sudden, reduced blood flow to the heart
EKG!!!
• Should be done within 10 min of arrival of pt to ED
DIFFERENTIALS
• Aortic dissection • Leaking or ruptured thoracic aneurysm • Pericarditis with tamponade • Pulmonary embolism • Pneumothorax • Peptic ulcer disease
UNSTABLE ANGINA
• ACS in which there is no detectable release of the enzymes and biomarkers of myocardial necrosis.
• Will have CP even at rest • May have ST changes on EKG
CANADIAN CLASSIFICATION SYSTEM
• Grade I – Angina with strenuous, rapid, or prolonged exertion; ordinary physical activity, such as climbing stairs, does not provoke angina
• Grade II – Slight limitation of ordinary activity; angina occurs with postprandial, uphill, or rapid walking; when walking more than 2 blocks of level ground or climbing more than 1 flight of stairs; during emotional stress; or in the early hours after awakening
• Grade III – Marked limitation of ordinary activity; angina occurs with walking 1-2 blocks or climbing a flight of stairs at a normal pace
• Grade IV – Inability to carry on any physical activity without discomfort; rest pain occurs
HIGH LIKELIHOOD OF PROGRESSION
• History of previous MI, sudden death, or other known history of CAD
• Chest, neck, jaw, or left arm pain consistent with prior documented angina
• Transient hemodynamic or ECG changes during pain
• ST-segment elevation or depression of 1 mm or more
• Marked symmetrical T-wave inversion in multiple precordial leads
LOW PROBABILITY OF PROGRESSION
• Chest pain classified as probably not angina • Chest discomfort reproduced by palpation • T-wave flattening or inversion of less than 1 mm in
leads with dominant R waves • Normal ECG findings
WORK UP
• 3 Serial troponins separated by 4-6 hours • EKG • CXR • CBC • CMP • ?echo • ?cardiac angiography
CARDIAC MARKERS/SIGNIFICANCE
EKG CRITERIA
• Remember 1 box of elevation or depression in limb leads
• 2 boxes of change in anterior leads
TREATMENT OF ANGINA-MEDICAL
• Aspirin*** • Beta-adrenergic blocking agents • Thienopyridines (eg, clopidogrel and prasugrel) • GP IIb/IIIa antagonists • Heparin • Direct thrombin inhibitors • Nitrates***
***MONA
TREATMENT
• Admission to either telemetry or CCU • Need cardiology consult-interventionalist (in case
progression)
NSTEMI
• ST depression with +cardiac biomarkers • Similar treatment as unstable angina • Admit to ICU • Cardiology consult • Medical Management
THE DRUGS
• ASA 324mg CHEWABLE PO • Nitro 0.3mg SL x 3 over 15 minutes or usually 1 inch
of paste • Heparin 5000 units bolus then heparin drip of 12-15
units/kg/hr (max: 1000 units/hr) • Beta Blockers PO (ex: metoprolol 50mg) • Plavix 300mg loading dose • Integrelin 180 mcg/kg bolus then 2mcg/kg/min (1
mcg if RF)
STEMI
• Send labs if have time otherwise, no need for biomarkers (we know they will be elevated)
• CXR if possible • Decide whether the patient will be treated with
thrombolysis or primary PCI should be made within 10 minutes
GOALS
• TpA– door to drug time of 30 min • PCI—door to baloon time of 90 min
ED TREATMENT--TPA
• ≤67 kg: 15 mg IVP bolus over 1-2 minutes, THEN 0.75 mg/kg IV infusion over 30 minutes (not to exceed 50 mg), and THEN 0.5 mg/kg IV over next 60 minutes (not to exceed 35 mg over 1 hr)
• >67 kg (100 mg total dose infused over 1.5 hr): 15 mg IVP bolus over 1-2 minutes, THEN 50 mg IV infusion over next 30 minutes, and THEN remaining 35 mg over next 60 minutes
ED TREATMENT-PCI
• CALL CATH LAB IMMEDIATELY (CODE CORE) • Give ASA • Give beta-blocker—NOT in cocaine use though • Some cards will have you start plavix in ED
ED TREATMENT
• Pt should be admitted to the ICU
AORTIC DISSECTION
RISK FACTORS
• HTN • Connective tissue dz (marfans) • Cocaine/amphetamine use • trauma
PRESENTATION
• 96 percent of acute aortic dissections could be identified based upon some combination of the following three clinical features:
-Abrupt onset of thoracic or abdominal pain with a sharp, tearing and/or ripping character -Mediastinal and/or aortic widening on chest radiograph -A variation in pulse (absence of a proximal extremity or carotid pulse) and/or blood pressure (>20 mmHg difference between the right and left arm) • May also have dizziness or Syncope
CLASSIFICATION
WORK UP
• D-dimer, troponins and LDH may be elevated • May see EKG changes • CXR wide mediastinum • CT chest (AAA protocol)/abdomen once pt is
stable enough • Can do TEE if not stable
TREATMENT
• Acute ascending aortic dissection (Stanford type A) is a surgical emergency
• Patients who are hemodynamically stable with uncomplicated aortic dissections confined to the descending thoracic aorta (Stanford type B) are best treated with medical therapy
TREATMENT-SURGICAL
• Need cardiothoracic immediately • Sustain hemodynamic stability • To OR for stenting
TREATMENT-MEDICAL
• morphine to adequately control pain • Intravenous beta blockers are initiated to reduce
the heart rate below 60 beats/min. • Nitroprusside can be added, if needed, to achieve
a systolic blood pressure of 100 to 120 mmHg. • Direct vasodilators, such as hydralazine, should
be avoided.
TIME TIME TIME
• REMEMBER that time is of essence in these conditions
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