P year‎ > ‎Medicine‎ > ‎

12.12.03 Chest pain

Aetiologies
  • Cardiac
  • Pulmonary
  • Vascular
  • Gastric
  • Chest wall

6 Big Risk Factors
  • Modifiable
    • Smoking
    • HTN
    • Diabetes
    • Hypercholesterolaemia
  • Non-modifiable
    • Family Hx
    • Previous MI

Non-ACS causes of Trop rise
  • Increased release
    • CPR
    • Myocarditis
    • PE
  • Reduced excretion
    • Renal impairment

ST elevation
  • Alternatives
    • > 2 mm in 2 contiguous chest leads
    • > 1 mm in 2 contiguous limb leads

MAN (MONA has changed gender)
  • Morphine
    • Mild vasodilator
    • Anxiolytic => Reduced sympathetic output => Reduced oxygen demand
  • Aspirin
  • Nitrate
    • Use an infusion rather than sublingual so you can titrate against BP
    • Primary effect is venodilation
      • Reduces preload and therefore oxygen demand
    • Also has small effect on coronary arteries

Reversible causes - Ts and Hs
  • Hypovolaemia
  • Hypoxia
  • Hyperkalaemia
  • Hypothermia
  • Tension pneumothorax
  • Tamponade
  • Toxins
  • Thrombosis

CPR
  • UNINTERRUPTED CPR is the best thing for mortality reduction
  • Supplies around 25% of normal cardiac output
  • Restart immediately after shocks (don't check rhythm)

Trop
  • Can interpret absolute value for the first time at 12 hrs
  • Or do baseline and 6 hrs, and look for a rise
  • "Official MI" = >100
  • Cutoff for admission = >14

Therapeutic hypothermia
  • Give 2 litres of ice-cold saline
  • 8% decrease in BMR for each degree Celcius drop

Notes
  • ACS is defined by PLAQUE RUPTURE
  • 10 % of unstable angina presentations progress to MI
  • "You're not dead until you're warm and dead"
  • Pain severity score is useful to monitor CHANGE
  • All defibrillators these days are biphasic
  • Non-shockable rhythms
    • PEA
    • Asystole
  • Risk scores in ACS
    • GRACE (recommended by NICE)
    • TIMI

Comments