Chest PainChest Pain

What must we learn?What must we learn?

1.1. EpidemiologyEpidemiology

2.2. PathophysiologyPathophysiology

3.3. Diagnostic ApproachDiagnostic Approach

4.4. Diagnostic Table Diagnostic Table

5.5. Management and DispositionManagement and Disposition

CaseCase

اورژانس 4242قاي قاي آآ بخش به گذشته شب از سينه قفسه درد شكايت با اورژانس ساله بخش به گذشته شب از سينه قفسه درد شكايت با ساله. است نموده .مراجعه است نموده چپ مراجعه سمت در هايي درد گذشته شب از مينمايد ذكر چپ بيمار سمت در هايي درد گذشته شب از مينمايد ذكر بيمار

حدود در كه دارد سينه حدود قفسه در كه دارد سينه محل 11قفسه به تيزدارد ماهيت ميكشد طول محل دقيقه به تيزدارد ماهيت ميكشد طول دقيقه . از ها درد نمينمايد تفاوتي فعاليت و استراحت حالت در و نميكشد تير . خاصي از ها درد نمينمايد تفاوتي فعاليت و استراحت حالت در و نميكشد تير خاصي

ذكر را تعريق و استفراغ تهوع انها با همراه شده تكرار مكررا گذشته ذكر شب را تعريق و استفراغ تهوع انها با همراه شده تكرار مكررا گذشته شب . . زير در اي نقطه را درد محل بيمار ميشود تشديد عميق تنفس با درد . نمينمايد . زير در اي نقطه را درد محل بيمار ميشود تشديد عميق تنفس با درد نمينمايد

. ميدهد نشان چپ .نيپل ميدهد نشان چپ نيپلدر سرماخوردگي بجز نميكند ذكر را خاصي بيماري سابقه در بيمار سرماخوردگي بجز نميكند ذكر را خاصي بيماري سابقه اخير چ چبيمار روز اخير ند روز ند

. نمينمايد مصرف نيز خاصي داروي .همچنين نمينمايد مصرف نيز خاصي داروي همچنين. نميدهد هم را مخدر مواد و الكل سيگار مصرف .سابقه نميدهد هم را مخدر مواد و الكل سيگار مصرف سابقه

ندارد خمصي ديسترس معاينه ندارد در خمصي ديسترس معاينه درBP= 110/85 mmHg PR=92/ Min RR= 16/Min T= 37.1 c ( oral )BP= 110/85 mmHg PR=92/ Min RR= 16/Min T= 37.1 c ( oral )

ناحيه روي بر موضعي تندرنس بجز معاينه ناحيه در روي بر موضعي تندرنس بجز معاينه .ApicalApicalدر ندارد حاصي .نكته ندارد حاصي نكتهچيست؟ شما چيست؟ تشخيس شما تشخيس

EpidemiologyEpidemiology

> 5 million/year patients of > 5 million/year patients of Emergency rooms Emergency rooms

A symptom caused by several A symptom caused by several life threatening disease life threatening disease

Accurately discerning the correct diagnosis and treatment of a chest pain is one of the most difficult tasks

EpidemiologyEpidemiology

Catastrophic causes are: Acute coronary syndromes (ACS) Aortic dissection Pulmonary embolus Pneumothorax Pericarditis with tamponade Esophageal rupture

ACS is the most significant potential diagnosis

Emergency physicians reportedly have missed 3% to 5% of MI accounting for 25% of malpractice

Most of the chest pains presenting to the ED have a benign origin

PathophysiologyPathophysiology

Afferent fibers from the heart, lungs, great vessels, and esophagus enter the same thoracic dorsal ganglia.

Dorsal segments overlap three segments above and below a level

Disease of a thoracic origin can produce pain anywhere from the jaw to the epigastrium

Radiation of pain is explained by somatic afferent fibers synapsing in the same dorsal root ganglia

PathophysiologyPathophysiology

The quality of visceral chest pain has been described as:

Burning Aching Stabbing Pressure

Typical ischemic chest Typical ischemic chest painpain

1.1. Retrosternal chest pressureRetrosternal chest pressure1.1. Burning or heavinessBurning or heaviness

2.2. Radiating occasionally to neck, jaw, Radiating occasionally to neck, jaw, epigastrium, shoulders, or left arm.epigastrium, shoulders, or left arm.

2.2. Precipitated by exercise, cold Precipitated by exercise, cold weather, or emotional stressweather, or emotional stress

3.3. Duration 2-10 minutesDuration 2-10 minutes

Atypical Chest PainAtypical Chest Pain

1.1. Pleuritic chest pain Pleuritic chest pain 2.2. In the middle or lower abdominal In the middle or lower abdominal

region.region.3.3. Localized at the tip of one finger, Localized at the tip of one finger,

particularly over the left ventricular particularly over the left ventricular ( LV ) apex.( LV ) apex.

4.4. Reproduced with movement or Reproduced with movement or palpitation of chest wall or arms.palpitation of chest wall or arms.

5.5. Constant for many hoursConstant for many hours6.6. Very brief episodes Very brief episodes 7.7. Radiates into the lower extremitiesRadiates into the lower extremities

Diagnostic ApproachDiagnostic Approach

Rapid Assessment and Stabilization

The first questions: 1. What are the life-threatening

possibilities in this patient2. Must I intervene immediately?

Assessing the patient's appearance and vital signs

Tension Pneumothorax

Diagnostic ApproachDiagnostic Approach

80% to 90% of information pertinent to the differential diagnosis is obtained by the history, physical examination and ECG.

1. History2. Physical Examination3. Ancillary Studies

History

A useful initial approach is to classify patients into three categories: Chest wall pain Pleuritic or respiratory chest pain Visceral chest pain

Pain, Associated syncope/near-syncope, Associated dyspnea, Associated hemoptysis, nausea and vomiting

Differential DiagnosisDifferential Diagnosis

1.1. Cardiac :Cardiac : Angina Angina unstable anginaunstable angina Acute MIAcute MI PericarditisPericarditis2.2. vascular:vascular: Aortic DissectionAortic Dissection Pulmonary Embolism Pulmonary Embolism pulmonary hypertensionpulmonary hypertension3.3. pulmonary:pulmonary: Pleuritis and/or pneumoniaPleuritis and/or pneumonia Tracheobronchitis Tracheobronchitis Spontaneous pneuomothoraxSpontaneous pneuomothorax4.4. GI:GI: Esophageal reflux Esophageal reflux Peptic ulcer Peptic ulcer Gallbladder diseaseGallbladder disease PancreatitisPancreatitis5.5. Musculoskeletal:Musculoskeletal: CostochondritisCostochondritis Cervical disc diseaseCervical disc disease6. 6. Infectious:Infectious: Herpes ZosterHerpes Zoster7. 7. Psychological:Psychological: Panic DisorderPanic Disorder

Ancillary Studies

Chest radiograph and 12-lead ECG

ECG should be performed in all patients 30 years old and older within 10 min of arrival

Ancillary Studies; Serum Markers

CK-MB values in healthy controls may be up to L and up to 5% of total CK.

Approach to Low Probability of Approach to Low Probability of IschemiaIschemia

1. History alone is not adequate to exclude the presence of acute ischemia

2. The goal should always be "zero tolerance" for missed AMI.

Approach to Low Probability of Approach to Low Probability of IschemiaIschemia

Approach to Low Probability of Approach to Low Probability of IschemiaIschemia

Initial assessment of critical diagnoses