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8/13/2019 Chest Pain Non Trauma
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Chest Pain
(Non - Trauma)Oleh :
M. Samsul Arifin 0810710072
Nur Hidayati Azar 0810710088
Peppy Tria 0810710092Tita Luthfia S 0810710107
Anantika Putri 0810713004
Arrasyid Indra 0710713025
Pembimbing :
dr. Munsifah Z., SpEM
FK UNIV. BRAWIJAYA/RSU DR. SAIFUL ANWAR
MALANG2013
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Introduction
Chest painmany
symptoms overlap
Goal in ED is to r/o life
threatening causesof chestpain
Need appropriate history,
physical exam, and ancillary
tests
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LIFE-THREATENING CAUSES
Acute myocardial infarction
Unstable angina
Aortic dissection
Pulmonary embolism
Tension pneumothorax
Oesophageal rupture
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NON LIFE-THREATENING CAUSES
Cardiac Stable angina
Prinzmetal angina
Pericarditis/myocarditis
Respiratory Simple pneumothoraxPneumonia with pleurisy
Gastrointestinal Reflux oesophagitis
Oesophageal spasm
Referred pain Gastritis/PUD
Biliary disease
Subphrenic abscess/inflammation
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Time & character ofonset
Quality
Location Radiation
Associated Symptoms
Chest Pain - History
Aggravating symptoms
Alleviating symptoms
Prior episodes
Severity Review risk factors
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Time & Character of Onset
Abrupt onset with greatest intensity at start :
Aortic dissection, PTX, Occasionally PE will present in this
manner
Chest pain lasting seconds or constant over weeks is not
likely to be due to ischemia
Pleuritic Pain: PE, Pleurisy, Pneumonia, Pericarditis, PTX
Esophageal: Burning
MI: squeezing, tightness, pressure, heavy weight on chest,
can also be burning
Sharp, tearing, ripping pain: Aortic Dissection
Quality
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If very localized, consider chest wall pain or pain of pleural
origin
Location
Associated Symptoms
Fevers, chills, URI symptoms, productive cough : Pneumonia Nausea, vomiting, diaphoresis, shortness of breath: MI Shortness of breath: PE, PTX, MI, Pneumonia, COPD/Asthma Asymmetric leg swelling: DVTPE
With new onset neurologic findings or limb ischemia:consider dissection Pain with swallowing, acid taste in mouth: Esophageal
disease
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Activity: Consider ischemic heart disease Food: Consider esophageal disease
Position: If worse with laying back, consider pericarditis.
Swallowing: Esophageal disease
Movement: Chest wall pain Respiration: PE, PTX, Pneumonia, pleurisy
Palpation: Chest Wall Pain
Aggravating Symptoms
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Alleviating Symptoms
Rest/ Cessation of Activity: Ischemic Sitting up: Pericarditis
Antacids: Usually GI system
Prior Episodes
Have they had this kind of pain before Does this feel like prior cardiac pain, esophageal pain, etc
What diagnostic work-up have they had so far? Last ECG,echo, last stress test, last cath, etc
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Risk Factor
Hypertension, DM, high cholesterol, tobacco, family history Long plane trips, car rides, recent surgery or immobility,
hypercoagulable state: PE
Uncontrolled HTN/ Marfans: Dissection
Rheumatic Diseases: Pleurisy Smoking: COPD, Ischemia
Severity
Severity of chest pain
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Chest PainPhysical Examination
Review vital signs* Fever: Pericarditis, Pneumonia
* Check BP in both arms: Dissection
* Decreased sats: More commonly in pneumonia, PE, COPD
* Unexplained sinus tachy: consider PE
Neck
* Look for tracheal deviation: PTX
* Look for JVD: Tension PTX, Tamponade, (CHF)
* Look for accessory muscle use: Respiratory Distress(COPD/ASTHMA)
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Chest PainPhysical Examination
Chest wall exam* Look for lesions: Herpes Zoster
* Palpate for localized tenderness: Likely musculoskeletal cause
Lung exam* Decreased breath sounds/hyperresonance: PTX
* Look for Rhonchi: Pneumonia
* Listen for wheezing/prolonged expiration: COPD
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Chest PainPhysical Examination
Cardiovascular Exam* Assess heart rate
* Listen for murmurs, S3/S4
* Pericardial friction rub: pericarditis
* Muffled heart sounds: Tamponade* Assess distal pulses
Abdominal Exam
* Assess RUQ and epigastrium
NEURO EXAM
* Chest pain +neurologic findings: consider dissection
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Chest PainAncillary Tests
LABS CBC, PT/PTT, D dimer (PE), Blood cultures(pneumonia), Sputum cultures (pneumonia), Peakflow (Asthma), ABG, Cardiac Enzymes (MI), ESR(pericarditis)
CXR - Rib fractures
- Hamptons Hump/Westermarkssign: PE
- Infiltrates: Pneumonia
- Widened mediastinum: Aortic dissection
- Pneumothorax
- Cardiac size: enlarged silhouette without CHF:pericardial effusion
ECG MI
CT Scan CT Scan Thorax if suspect PE or Aortic Dissection
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Management Non Traumatic
Chest Pain
Ensure vital sign are stable. If unstable, patient in distress
and diaphoretic, bring patient to resuscitation area
immediately
Put patient on oxygen supplementation, pulse oximetry,continuous ECG monitoring, blood pressure monitoring
Set up IV line and take blood test
Give pain relief depending on provisional diagnosis
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ACUTE MYOCARDIAL INFARCTION (AMI)
Definisi
Sering disebut serangan jantung, merupakan akibat darigangguan aliran darah ke bagian jantung, menyebabkan
kematian sel jantung mati.
Tanda dan Gejala
Nyeri dada tiba-tiba (menyebar ke lengan kiri atau lehersebelah kiri), sesak nafas, nausea, vomiting, palpitasi,berkeringat, dan cemas.
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Management AMI
O2Aspirin 300-
320 mgCPG 300
mg
S/L GTN 1 tabstat, repeatECG after 5minutes (to
exclude ECGchanges dtcoronary
spasm)
Morphine iv
2-5 mgslow bolus
(ifnecessary)
IV GTN 20-200microgram/min, increase by 5-
10microgram/min
at 5-10 minintervals (ifnecessary)
Considermyocardial
salvagetherapy
Considerthrombolytic
therapy
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Indikasi Terapi Thrombolytic
Typical chest pain of AMI
ST elevation of at least 1 mm in at least 2 inferior ECG
leads or elevation of at least 2 mm in at least 2
contiguous anterior leads
< 12 h from chest pain onset
< 75 y.o of age
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UNSTABLE ANGINA PECTORIS
Unstableanginaresults
from thesudden
rupture of aplaque
Rapidaccumulationof platelets at
the rupturesite and asudden
increase inobstruction toblood flow inthe coronary
artery
Accumulation
of plateletsandobstruction toblood flow can
result in aheart attack
Risk of heartattack remains
even if theunstableangina
symptomslessen ordisappear
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Tanda dan Gejala UAP
Bisa berlangsung selama 5-20 menit. Gejala yang dirasakan :
Nyeri atau tertekan
Rasa berat dan tidak nyaman pada dada, leher,
kerongkongan, bahu dan lengan
Rasa terbakar atau indigestion Sesak
Unstable angina terjadi tanpa didahului tanda awal dan
terjadi saat istirahat sehingga sering mengakibatkan ansietas.
Gejala lain yang bisa terjadi : Mual
Nyeri kepala
Keringat berlebihan
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Management UAP
Nitrates
- Dilatasi pembuluh darah
- Mengurangi resistensi pembuluh darahmengurangi
kerja jantung (workload) Beta-blockers
- Memperlambat denyut jantung dan mengurangi tekanan
kontraksi otot jantung
Calcium channel blockers
- Dilatasi pembuluh darah dan mengurangi tekanan darah
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PULMONARY EMBOLISM (PE)
PE is a blockage of themain artery of the lungor
one of its branches by a
substance that has
travelled from elsewherein the body through the
bloodstream (embolism)
Origin >> DVT
Virchows Triad(Endothelial Injury, Stasis,
Hypercoagulability)
http://en.wikipedia.org/wiki/Pulmonary_arteryhttp://en.wikipedia.org/wiki/Embolismhttp://en.wikipedia.org/wiki/Embolismhttp://en.wikipedia.org/wiki/Pulmonary_artery8/13/2019 Chest Pain Non Trauma
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Clinical Symptoms of PE
Clinical symptoms suggestive of PE: Dyspnea
Chest pain (Pleuritic/non pleuritic)
Cough
Orthopnea Calf and/or thigh pain or swelling
Wheezing
Common signs:
Tachypnea
Tachycardia
Rales
Decreased breath sounds Jugular venous distension
Accentuated pulmonic
component of second
heart sound
Symptoms/ signs of lower extremity DVT include :
edema, erythema, tenderness or a palpable cord.
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PE Management
Initiate Heparin- Unfractionated Heparin: 80 Units/Kg bolus IV, then
18units/kg/hr
- Fractionated Heparin (Lovenox): 1mg/kg SubQ BID
- If high pre-test probability for PE, initiate empiric heparinwhile waiting for imaging
- Make sure no intraparenchymal brain hemorrhage or GI
hemorrhage prior to initiating heparin.
Consider Fibrinolytic Therapy:
- Especially if PE + hypotension
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PE Management
Surgery and Other Prosedure Consider Clot removal. For a very large clot in lung and in
shock, doctor may thread a thin flexible tube (catheter)
through blood vessels and suction out the clot.
Vein filter.Filter insertion is typically reserved for peoplewho can't take anticoagulant drugs or when anticoagulant
drugs don't work well enough
Surgery.IThis happens infrequently, and the goal is to
remove as many blood clots as possible, especially if there'sa large clot in main (central) pulmonary artery.
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AORTIC DISSECTION
Aortic dissection is an acute event where blood enters
the aortic wall through a tear of the intima followed by
extravasation of blood into the media.
Currently believed the process begins with an intramuralhematoma
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Etiology
Degenerative
Hypertension
Pregnancy
Skeletal (scoliosis) Connective tissue (Marfans)
Mycotic aneurysm
Takayasu (giant cell) arteritis
Aortic laceration/coarctation
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Aortic Dissection
Stanford Classification
Type A -involves ascending
aorta
Type Binvolves
descending aorta
DeBakey Classification
Type Iascending, arch &
descending aorta
Type IIascending only
Type IIIdescending only
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Aortic Dissection
ClinicalFeatures
>85%abrupt,
severe painin chest or
b/wscapula
50%ripping or
tearing
Pain inanteriorchest
ascendingaorta (70%)
Back pain(less
common)descendingaorta (63%)
Ifdissection
into carotidclassic
neurosymptoms
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Aortic Dissection
Physical Exam
Usually normal heart and lung exam
May have aortic insufficiency
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Aortic Dissection
T
reathype
rtension-blocker
Esmolol 500g/kgIV bolus over 1minute then 50-
150 g/kg minute
Metoprolol 5mgq2min x3 IV then 2-5mg/hr
Propranolol 20mgIV then 40mg, 8-mg q10min to
300mg totalCalcium channel
blocker if -blockercontraindicated
Va
sodilatorNitroprusside 0.3
g/kg/min IV
SurgeryOR for ascending
aortic dissection
Descending aorticdissection worsesurgical risks
controversial forrepair
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Trachea deviates to contralateral side
Mediastinum shifts to contralateral side
Decreased breath sounds and hyperresonance on affectedside
JVD
Treatment: Emergent needle decompression followed bychest tube insertion
TENSION PNEUMOTHORAX
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NEEDLE DECOMPRESSION
Insert large bore needle (14 or 16 Gauge) with catheter inthe 2nd intercostal space mid-clavicular line. Removeneedle and leave catheter in place. Should hear air.
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Nyeri dada pleuritik
Lokasinya posterior atau lateral. Sifatnya tajam dan
seperti ditusuk.
Bertambah nyeri bila batuk atau bernafas dalam dan
berkurang bila menahan nafas atau sisi dada yang sakit
digerakan.
Nyeri berasal dari dinding dada, otot, iga, pleura
perietalis, saluran nafas besar, diafragma, mediastinum
dan saraf interkostalis.
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Nyeri dada Non- pleuritik
Lokasinya sentral, menetap atau dapat menyebar ke
tempat lain.
Sering disebabkan oleh kelainan di luar paru.
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Nyeri Dada
Non
Pleuritik
Kardial
Perikardial
Aorta
Muskulo
skleletal
Fungsional
Pulmonal
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Trauma lokal atau radang dari rongga dada otot, tulangkartilago sering menyebabkan nyeri dada setempat.
Nyeri biasanya timbul setelah aktivitas fisik.
Muskulo
skeletal
Kecemasan dapat menyebabkan nyeri substernal atauprekordinal, rasa tidak enak di dada, palpilasi, dispnea,using dan rasa takut mati.
Fungsional
Obstruksi saluran nafas atas seperti pada penderitainfeksi laring kronis dapat menyebakan nyeri dada,terutama terjadi pada waktu menelan.
Pada emboli paru akut nyeri dada menyerupai infarkmiokard akut dan substernal.
Nyeri dada merupakan keluhan utama pada kanker paruyang menyebar ke pleura, organ medianal atau dindingdada.
Pulmonal
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Angina stabil (Angina klasik, Angina of Effort), Angina takstabil (Angina preinfark, Insufisiensi koroner akut) ,Infark miokard
Kardial
Saraf sensoris untuk nyeri terdapat pada perikardiumparietalis diatas diafragma. Nyeri perikardila lokasinya di
daerah sternal dan area preokordinal, tetapi dapatmenyebar ke epigastrium, leher, bahu dan punggung
Nyeri bisanya seperti ditusuk dan timbul pada aktumenarik nafas dalam, menelan, miring atau bergerak.
Perikardial
Penderita hipertensi, koartasio aorta, trauma dindingdada merupakan resiko tinggi untuk pendesakan aorta.
Diagnosa dicurigai bila rasa nyeri dada depan yang hebattimbul tiba- tiba atau nyeri interskapuler
Aorta
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