Chest Pain and Cardiac Emergencies 2015

Chest Pain and Cardiac Emergencies

Welcome

Chest Pain

Certainty

Simulation

Introduction

• Chest Pain is common– 6 potentially lethal causes to remember– Traditional approach (*full Hx) may be suboptimal

• Assessment and Management should focus on– ABCDEFG and ECG– IV access, M.O.N.A. (may not be right anymore)– Senior review (#8500/mobile or Medical Registrar)

Approach – Traditional vs. Emergency

Life Threats

Serious Causes

Benign Causes (Common)

Lethal Causes

• Myocardial Infarction (MI)• Pulmonary Embolism (PE)• Aortic Dissection (AD)• Pneumothorax (Tension Pneumothorax)• Pneumonia and Sepsis• Oesophageal Perforation

Myocardial Infarction and the Acute Coronary

Syndromes

ECG

ECG 1

Acute Coronary Syndrome

Assessment

Assessment

• Assessment– DETECT ABC approach

• Pitfalls– Elderly Patients are

often pain free– MI patients may

have NO risk factors

Acute Coronary Syndromes (ACS)

Acute Coronary Syndromes

STEMI(30%)

NSTEMI(25%)

UAP(35%)

Atypical = Typical

Acute Coronary Syndrome

Management

Management – MONA

• Morphine – 0.1mg/kg IV and reassessment • Oxygen – titrated to 94% (no longer

routine)• Nitrate – with care (avoid in RV

infarction)• Aspirin – have a high threshold for not

giving – low NNT and good

safety profile• Other (ABCDEFG)– ACE Inhibitor, β Blockers, Clopidogrel & Prasugrel– Don’t ever forget glucose (BSL)– Fluids (often required in RV infarction)

Management

DOCUMENT

YOUR PLAN

CLEARLY

Referral – “ISBAR”

• Page 8500 and/or Cath Lab Team (STEMI)• Your Registrar Consultant (in hours) • Medical Registrar (out of hours)• Intro - I am Andrew the Intern covering A5C• Situation and Background - I have Mrs Smith

who is in hospital with abdominal pain that was thought to be from Gallstones – she now has Chest pain & ST Elevation in AVF, II and III

• Assessment – obs Response – review

COMMUNICATE

EFFICIENTLY

AND CLEARLY

Management

• Resuscitation, Specific (MONA) and Supportive• Disposition– Catheter Laboratory– Cardiac Unit (A5a, A5c)– CCU (A5b)– Cardiothoracics (C3c and D3c)– Respiratory Ward - PE and Pneumothorax (B5a)– ICU (E3a and E3b)– Home & follow up (e.g. EST, Cardiac CT, MIBI, Echo)

Chest Pain

Risk Stratification and State Policy

ALL PROTOCOLS

ARE ON ED

INTRANET

Other Causes of Chest Pain

Pulmonary Embolism

Aortic Dissection• Uncommon 5/100,000• Overall Mortality is 27% in hospital, 1% per

hour and >90% untreated• Ratio of MI to Dissection is 3000:5 (so it is

often missed and treated as MI) • Risk Factors – Hypertension, Cardiothoracic Surgery, Collagen

Vascular Disease • Stanford – A & B (‘A’ proximal involvement)• CXR and BP both arms have limited value!

Pneumothorax

Arrhythmia

Recognition and Management

Has the patient arrested?

Perfusion

No Pulse

ALS Algorithm

Pulse

Assessment of Stability

Is the patient stable?Are there any adverse signs?

Stability and Adverse Signs

Extremes of Heart Rate

*Blood Pressure and Perfusion Chest Pain Signs of Acute

Heart Failure

Arrhythmias

• The Mantra / Approach– How is the patient? What is the Cause?– IV, O2, Monitor– Call for assistance

• Assessment of Rhythm– Assessment of Pulse and Adverse Features– Narrow Complex vs. Broad Complex– Regular vs. Irregular– Slow, Fast vs. Very Fast

Causes of Bradycardia/Tachycardia?

Drugs

Ischaemia

Electrolytes

Take Home

• 6 lethal causes• ‘Atypical = Typical’ (Non-cardiac = Non-cardiac)• A – G approach • Serial ECGs • Call for senior help • Call for help (ALS team) for patients with adverse

signs including refractory chest pain, shock, extremes of heart rate and cardiac failure