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