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