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So, back to our case study
Management?
ECG shows...
ECG looked abnormal.
Sounded like cardiac chest pain with hx of IHD.
FY1 gave 225mg aspirin and 2 puffs GTN
Not incorrect
ECG = early repolarisation (high-take off)
Troponin normal
A - own, patent
B - speaking full sentences. RR 14. SpO2 98%.
equal lung expansion
vesicular sounds bilaterally, nil added
C - HR 86. BP 135/89.HS I+II+0, no murmurs, JVP equivocal, calves SNT. Radial pulses strong, regular, equal.
D - GCS 15. PERRLA. No rashes/bruises. Temp 36.8c
E - abdo soft, tender epigastrum, no peritonism. BS present. No masses.
Respiratory Causes
Cardiac Causes
Others
1. Check NEWS score
2. Look at the patient - eyeball them yourselves
3. Call for help as soon as you think you might need it
4. Don't be afraid to put out 2222
5. Take a good chest pain history
6. A-E examination helpful for exam and writing notes
7. Come up with some differentials - don't be afraid to initiate urgent treatment
8. Check with your senior if you aren't sure
9. Ensure patient is comfortable
10. May need to multitask or change order of assessment depending on presentation
Musculoskeletal
Costochondritis
Conversion disorder
Factitious disorder
Malingering
Anxiety
Gastrointestinal
When to get help?
As soon as you feel you need it
Remember -
Never ever be afraid to ask for help
As soon as it enters your head to get a senior - do it
No-one will ever get annoyed at you for asking for help
What to do while waiting for help?
A - BMV or airway adjunct
B - give oxygen/ start nebulisers
C - chest compressions?
take an ECG
D - ensure IV access (+ working!)
start stat bag of fluids
E - start anaelgesia
order an X-ray
2222 - arrest/ periarrest
Will depend on what information you have and what history taking indicates...
S - retrosternal
O - when smoking down in cold wind
C - dull. similar to prior angina
R - epigastrum
A - nausea, mild SOBOE
T - constant since onset
E - GTN no improvement; rest has helped SOB
S - 6/10
56 y.o M
Alcoholic with chronic pancreatitis
Known IHD and HTN
Meds: Aspirin, GTN, ACEI, Thiamine
Usually exertional CP but infrequent
Smoker
Sedentary lifestyle
NKDA
No illicit drug use
Anaelgesia
Oxygen
Aspirin
Nitrates
Further advice
Investigations
- ECG
- consider CXR
- consider bloods
- troponin
- ? D-dimer - risk score Well's
Examination
Respiratory Exam
Equal a/e bilaterally?
Equal lung expansion?
Central trachea?
Cyanosis?
Clubbing?
Added lung sounds?
Percussion abnormalities?
A-E is really useful
Doesn't miss anything
CVS examination
Tender abdomen?
Any masses/organomegaly?
Reproducible chest wall pain?
Any bruises?
Murmurs?
JVP increased?
Soft non-tender calves?
Strong regular radial pulses?
NEWS - validated score
Respiratory rate - have they respiratory distress?
SpO2 - do they need oxygen?
HR - tachy or brady?
BP - hypotension or HTN?
Temp - any pyrexia present ?infection
Really good mortality risk indicator
Gives a lot of useful information fast - but need to know data, not just the score
Observation!!
History
NEWS score
- 56 yr old male
- out downstairs smoking at 3am
- admitted with worsening epigastric pain
- known alcoholic with chronic pancreatitis
- came back to ward with central chest pain
- no response to own GTN
- please come and review
What do you want to do?
1. Airway patent
2. Speaking comfortably
3. Any resp distress/accessory muscle use/tripoding?
4. Appears to be in pain?
5. Diaphoretic or flushed?
6. Around the bed clues?
ABCDE approach
Need help?