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Any questions?

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.

Patient Review: Chest Pain

Reasons for chest pain

10 Take-away Points

Respiratory Causes

Cardiac Causes

  • PE
  • Pleuritis
  • Pneumonia
  • Pneumothorax
  • ACS - STEMI/NSTEMI/UA
  • Angina - stable/unstable/Prinzmetals'
  • Aortic aneurysm
  • PE
  • cardiomyopathy
  • myocarditis
  • pericarditis
  • mitral valve prolapse

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

  • GORD
  • Peptic ulcer disease
  • Oesophageal spasm
  • cholecystitis
  • Mallory-Weiss tear
  • Boerhaave syndrome

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

Management of chest pain

From the case study

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

Case Presentation

How to review a patient with chest pain

History Taking

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?

SOCRATES

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

  • Reason for admission
  • Prior similar episodes
  • PMHx
  • PSHx
  • Meds
  • Allergies
  • SHx

Need help?

ATSP: CHEST PAIN

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