differential diagnosis of chest pain by dr farooq on 29 02-30 h
TRANSCRIPT
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IN THE NAME OF ALLAH THE MOST GRACIOUS,THE MOST MERCIFUL
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DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSISOFOF
CHEST PAINCHEST PAIN
DR.MUHAMMAD FAROOQUE
MB BS DTCD
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Chest PainChest Pain
5 Million emergency department visits5 Million emergency department visits2 million hospitalizations annually with cost 2 million hospitalizations annually with cost
of more than $8 billionof more than $8 billionCardiac etiology found in less than one Cardiac etiology found in less than one
thirdthird2% of patients with acute MI are 2% of patients with acute MI are
unrecognized and discharged from the EDunrecognized and discharged from the ED
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GoalsGoals
1.1. Rapid recognition of management of true Rapid recognition of management of true ACSACS
2.2. Recognition of other life-threatening causes Recognition of other life-threatening causes of chest painof chest pain
3.3. Minimize cost and hospitalization in patients Minimize cost and hospitalization in patients with chest pain of benign etiology.with chest pain of benign etiology.
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Chest Pain DiagnosisChest Pain Diagnosis
Clinical diagnosisClinical diagnosisDiagnosis using computer algorithmsDiagnosis using computer algorithmsChest pain centersChest pain centers
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CHEST PAIN (1429)CHEST PAIN (1429)
TOTAL PATIENTS=544TOTAL PATIENTS=544 IHD= 518IHD= 518CCF= 19CCF= 19MI MI DIAGNOSED ON ECGDIAGNOSED ON ECG =7 =7
COURTESY:HAMAD RASHID AL-MONAJAM
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PAINPAINJUST A CURSEJUST A CURSE
ORORA MERCY OF GODA MERCY OF GOD
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PAIN?PAIN? UNIVERSALLY UNDERSTOOD AS UNIVERSALLY UNDERSTOOD AS
“DISEASE SIGNAL”“DISEASE SIGNAL” MOST COMMON SYMPTOM THAT MOST COMMON SYMPTOM THAT
BRINGS A PATIENT TO A BRINGS A PATIENT TO A PHYSICIAN`S ATTENTION.PHYSICIAN`S ATTENTION.
AN UNPLEASANT SENSATION AN UNPLEASANT SENSATION LOCALIZED TO A PART OF THE LOCALIZED TO A PART OF THE BODYBODY
ITS BOTH SENSATION AND ITS BOTH SENSATION AND EMOTIONEMOTION
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ITS BOTH ITS BOTH SENSATION SENSATION
AND AND EMOTIONEMOTION
ACCOMPANIED BY ANXIETYACCOMPANIED BY ANXIETYACCAMPANIED BY URGE TO ESCAPE ACCAMPANIED BY URGE TO ESCAPE
OR TERMINATE THE FEELINGOR TERMINATE THE FEELING
DUALITY OF PAIN
PAIN
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PAINPAINHOW DESCRIBED?HOW DESCRIBED?
STABBINGSTABBINGBURNINGBURNINGTWISTINGTWISTINGTEARINGTEARINGSQUEEZINGSQUEEZINGTERRIFYINGTERRIFYINGNAUSEATINGNAUSEATINGSICKENINGSICKENING
PENETRATINGOR
TISSUE-DESTRUCTIVEPROCESS
BODILYOR
EMOTIONAL REACTION
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ACUTE PAINACUTE PAIN
BEHAVIORAL AROUSALBEHAVIORAL AROUSAL STRESS RESPONSESTRESS RESPONSE
LOCAL MUSCLE CONTRACTIONLOCAL MUSCLE CONTRACTION
INC BPINC HRINC PUPIL DIAMETERINC PLASMA CORTISOL LEVEL
ASSOCIATED ASSOCIATED WITHWITH
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PAIN IN THE CHESTPAIN IN THE CHESTBUTBUT
ORIGIN??ORIGIN??
HEARTHEART LUNGSLUNGS OESOPHAGUSOESOPHAGUS MUSCULOSKELETAL STRUCTURES OF MUSCULOSKELETAL STRUCTURES OF
THORAX NECK,OR SHOULDERTHORAX NECK,OR SHOULDER ABDOMENABDOMEN ANXIETY MANIFESTATIONANXIETY MANIFESTATION
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CHEST PAIN CLASSIFICATIONCHEST PAIN CLASSIFICATIONFROM CLINICAL VIEW POINT:FROM CLINICAL VIEW POINT:
RECURRENTOFTEN PAROXYSMALMILD OR MODERATE
ANGINAMUSCULOSKELETAL PAINS
SEVERE PROLONGED
ASSOCIATED WITHCLINICAL EVIDENCE OF ACUTE
SERIOUS ILLNESS
1 2
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WHAT LIES IN THE CHEST?WHAT LIES IN THE CHEST?
SKINSKINMUSCLESMUSCLESBONESBONESJOINTSJOINTSHEART AND VESSELSHEART AND VESSELSLUNGS AND AIRWAYSLUNGS AND AIRWAYSOESOPHAGUSOESOPHAGUSNERVESNERVES
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CHEST PAIN ASSESSMENTCHEST PAIN ASSESSMENT
HISTORY HISTORY EXAMINATIONEXAMINATIONECGECGCARDIAC ENZYMESCARDIAC ENZYMESCXRCXROTHERSOTHERS
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INITIAL APPROACHINITIAL APPROACH
Assume the worst!Assume the worst!100% Oxygen100% Oxygen IV accessIV accessMonitoringMonitoringECG quicklyECG quicklyDone in tandem with history takingDone in tandem with history taking
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TIME IS VITALTIME IS VITAL
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CHEST PAINCHEST PAIN
COMMON PRESENTATION TO A&ECOMMON PRESENTATION TO A&E
TRIVIAL TO LIFE-THREATENING CAUSESTRIVIAL TO LIFE-THREATENING CAUSES
KEY TO DIAGNOSIS IS HISTORYKEY TO DIAGNOSIS IS HISTORY
NEGATIVE BASELINE INVESTIGATIONS DO NEGATIVE BASELINE INVESTIGATIONS DO NOT RULE OUT SERIOUS CONDITIONS NOT RULE OUT SERIOUS CONDITIONS
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HEART ATTACKHEART ATTACK
ANSWER IS ANSWER IS NONO…………
RELAXRELAX IS IT ENOUGH TO RULE OUT HEART IS IT ENOUGH TO RULE OUT HEART
ATTACK?ATTACK?
LIFE THREATENING CHEST PAIN INTHE EMERGENCY DEPARTMENT
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Life Threatening Chest Pain inthe Emergency Department
• Myocardial Infarction • USA• Aortic Dissection• Tension Pneumothorax• Pulmonary Embolus• Ruptured Esophagus/Perforated Ulcer
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COMMON CAUSES OF CHEST PAINCOMMON CAUSES OF CHEST PAIN ANXIETYANXIETY
CARDIACCARDIAC
AORTICAORTIC
OESOPHAGEALOESOPHAGEAL
LUNGS/PLEURALUNGS/PLEURA
MUSCULOSKELETALMUSCULOSKELETAL
NEUROLOGICALNEUROLOGICAL
MYOCARDIAL ISCHEMIA(ANGINA)MIMYOCARDITISPERICARDITISMVP
AORTIC DISSECTIONAORTIC ANEURYSM
ESOPHAGITISESOPH SPASMMW SYNDROME
BRONCHOSPASM:::::PE:::PIPNEUMONIA:::::TB:::::::CTDsTRACHEITIS PLEURITISPNEUMOTHORAX MALIGNANCY
OARIB #I/C MUSCLE INJURYTEITZE`S SYNDBORNHOLM`S DISEASE
PROLAPSED I/V DISCHERPES ZOSTERTHORACIC OUTLET SYNDROME
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CARDIACCARDIACOROR
NON-CARDIAC PAIN?NON-CARDIAC PAIN?
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Chest Pain: HistoryChest Pain: History
P: pattern (temporal sequence)P: pattern (temporal sequence) A: associated features A: associated features
SOB, N/V, diaphoresisSOB, N/V, diaphoresis fever, cough, chillsfever, cough, chills abdominal painabdominal pain
I: initiation and improvementI: initiation and improvement N: nature (quality)N: nature (quality)
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CHEST PAIN ASSESSMENTCHEST PAIN ASSESSMENT
History History VITALLY IMPORTANTVITALLY IMPORTANT
PAIN PAIN NATURENATURE SITESITE SEVERITYSEVERITY RADIATIONRADIATION ONSETONSET EXAC/RELIEVING FACTORSEXAC/RELIEVING FACTORS ASSOCIATED FEATURESASSOCIATED FEATURES DURATIONDURATION PREVIOUS SIMILAR PAINSPREVIOUS SIMILAR PAINS
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Chest Pain: Physical ExamChest Pain: Physical Exam Vital signs and general appearanceVital signs and general appearance Carotids and JVPCarotids and JVP LungsLungs Cardiac examCardiac exam Thoracic cageThoracic cage Abdominal examAbdominal exam Periphery (pulses)Periphery (pulses) SkinSkin
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CHEST PAIN ASSESSMENTCHEST PAIN ASSESSMENT
ExaminationExaminationGeneral ExaminationGeneral Examination
((sweaty clammy pale cyanosed, anaemic etc pulse BP)sweaty clammy pale cyanosed, anaemic etc pulse BP)
Cardiovascular /Respiratory examinationCardiovascular /Respiratory examination
? Failure ( crackles ,oedema, raised JVP)? Failure ( crackles ,oedema, raised JVP)
Heart SoundsHeart Sounds - - rate , nature ,?quiet ? added heart sounds, ?rate , nature ,?quiet ? added heart sounds, ?
murmurs murmurs
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Chest Pain: LocationChest Pain: LocationMyocardial Myocardial ischemiaischemiaPericarditisPericarditisPleurisy, Sub-diap Pleurisy, Sub-diap abscessabscess
Myocardial ischemiaMyocardial ischemiaCervical spineCervical spineThoracic outletThoracic outlet
Pulmonary embolismPulmonary embolismPneumoniaPneumoniaSplenic infarctionSplenic infarctionSubdiap. abscessSubdiap. abscess
Myocardial ischemiaMyocardial ischemiaPericarditisPericarditisAortic dissectionAortic dissectionMediastinal lesionMediastinal lesionPulmonary embolismPulmonary embolismEsophageal spasmEsophageal spasm
CholecystitisCholecystitisHepatic distensionHepatic distensionPeptic diseasePeptic diseasePancreatitisPancreatitisMyocardial ischemiaMyocardial ischemia
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LOCATIONLOCATION CENTRAL,CENTRAL,
DIFFUSEDIFFUSE
PERIPHERALPERIPHERAL
LOCALIZEDLOCALIZED
RADIATIONRADIATION JAW/NECK/SHOULDER/ JAW/NECK/SHOULDER/ OCCASIONALLY BACKOCCASIONALLY BACK
OTHER OROTHER OR
NO RADIATIONNO RADIATION
CHARACTERCHARACTER TIGHTTIGHT
SQUEEZINGSQUEEZING
CHOKINGCHOKING
SHARPSHARP
STABBINGSTABBING
CATCHINGCATCHING
PRECIPITATIONPRECIPITATION EXERTIONEXERTION
EMOTIONEMOTION
SPONTANEOUSSPONTANEOUS
NOT RELATED TO EXERTIONNOT RELATED TO EXERTION
PROVOKED BY POSTURE,PROVOKED BY POSTURE,
RESPIRATION OR PALPATIONRESPIRATION OR PALPATION
RELIEVINGRELIEVING
FACTORSFACTORS
RESTREST
NITRATESNITRATES
NOT RELIEVED BY RESTNOT RELIEVED BY REST
SLOW OR NO RESPONSE BY SLOW OR NO RESPONSE BY NITRATESNITRATES
ASSOCIATED ASSOCIATED FEATURESFEATURES
BREATHLESSNESSBREATHLESSNESS RESP; GIT,LOCOMOTOR, ORRESP; GIT,LOCOMOTOR, OR
PSYCHOLOGICALPSYCHOLOGICAL
ISCHEMIC CARDIAC PAIN NON-CARDIAC PAINV/S
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MYOCARDIAL ISCHEMIA(ANGINA)MIMYOCARDITISPERICARDITISMVP
AORTIC DISSECTIONAORTIC ANEURYSM
ESOPHAGITISESOPH SPASMMW SYNDROME
BRONCHOSPASM:::::PE:::PIPNEUMONIA:::::TB:::::::CTDsTRACHEITIS PLEURITISPNEUMOTHORAXMALIGNANCY
OARIB #I/C MUSCLE INJURYTEITZE`S SYNDBORNHOLM`S DISEASE
PROLAPSED I/V DISCHERPES ZOSTERTHORACIC OUTLET SYNDROME
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ANXIETYANXIETY
ANXIOUS THOUGHTSANXIOUS THOUGHTS AVOIDANCE BEHAVIOURAVOIDANCE BEHAVIOUR SOMATIC SYMPTOMSSOMATIC SYMPTOMS STRESSSTRESS H/O UNPLEASANT INCIDENCEH/O UNPLEASANT INCIDENCE HYPERVENTILATIONHYPERVENTILATION BREATHLESSNESSBREATHLESSNESS PALPITATIONPALPITATION CHEST PAINCHEST PAIN HEADACHEHEADACHE TINGLING SENSATIONTINGLING SENSATION NAUSEANAUSEA LBMLBM URINARY FREQUENCYURINARY FREQUENCY
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ISCHEMIC CARDIAC PAINISCHEMIC CARDIAC PAINORIGIN?ORIGIN?
SITE OF ORIGIN OF PAIN CENTRAL
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ISCHEMIC CARDIAC PAINISCHEMIC CARDIAC PAIN
MAY RADIATE TO NECKMAY RADIATE TO NECK JAWJAW UPPER OR LOWER ARMUPPER OR LOWER ARM BACKBACK
RADIATION
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ISCHEMIC CARDIAC PAINISCHEMIC CARDIAC PAIN
PLEURAL PROBLEMSPLEURAL PROBLEMS LUNG PROBLEMSLUNG PROBLEMS MUSCULOSKELETAL MUSCULOSKELETAL ANXIETYANXIETY
PAIN RADIATION OTHER POSSIBILITIES
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ISCHEMIC CARDIAC ISCHEMIC CARDIAC PAINPAINOROR
DISCOMFORTDISCOMFORT
TYPICALLY DULLTYPICALLY DULL CONSTRICTINGCONSTRICTING CHOKINGCHOKING HEAVYHEAVY USUALLY DESCRIBED BY USUALLY DESCRIBED BY
PATIENTS AS---SQUEEZING— PATIENTS AS---SQUEEZING— CRUSHING---- CRUSHING---- BURNING------- ACHING BURNING------- ACHING BUT NOT SHARP BUT NOT SHARP BUT NOT STABBING BUT NOT STABBING BUT NOT BUT NOT PRICKING BUT NOT PRICKING BUT NOT KNIFE-LIKEKNIFE-LIKE
SENSATION CAN BE DESCRIBED SENSATION CAN BE DESCRIBED AS BREATHLESSNESSAS BREATHLESSNESS
CHARACTER OF PAIN
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ISCHEMIC CARDIAC ISCHEMIC CARDIAC PAINPAINOROR
DISCOMFORTDISCOMFORT
EXERTIONEXERTION EMOTIONSEMOTIONS LARGE MEALSLARGE MEALS COLD WINDCOLD WIND UA AT RESTUA AT REST LYING DOWN LYING DOWN
(DECUBITUS ANGINA)(DECUBITUS ANGINA)
PROVOCATION
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PLEURAL OR PERICARDIAL PAINPLEURAL OR PERICARDIAL PAIN
MUSCULOSKELETAL PAINMUSCULOSKELETAL PAIN
PROVOCATION
CHEST PAINOTHER THAN
CARDIAC CAUSES
SHARP OR CATCHING SENSATIONEXACERBATED BY COUGHMOVEMENT
PAIN ASS WITH SPECIFIC MOVEMENT
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ISCHEMIC CARDIAC ISCHEMIC CARDIAC PAINPAINOROR
DISCOMFORTDISCOMFORT
GRADUAL ONSET GRADUAL ONSET OVER MINUTES OVER MINUTES DURING EXERTIONDURING EXERTION
PATTERN OF ONSET
MUSCULAR PAINOCCURS AFTER
EXERTION
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SUDDENSUDDEN INSTANTANEOUSINSTANTANEOUS
CHEST PAINPATTERN OF ONSET
DISSECTING AORTIC ANEURYSM
TENSION
PNEUMOTHORAX
MASSIVE P E
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ISCHEMIC CARDIAC ISCHEMIC CARDIAC PAINPAINOROR
DISCOMFORTDISCOMFORT
SWEATINGSWEATING NAUSEANAUSEA VOMITINGVOMITING BREATHLESSNESSBREATHLESSNESS COUGHCOUGH WHEEZEWHEEZE
ASSOCIATED FEATURES
MASSIVE PULM EMBOLISM AND
AORTIC DISSECTION ALSO ACCOMPANIED BY
AUTONOMIC DISTURBANCES
CLASSIC GI SYMPTOMSOESOPHAGEAL REFLUXOESOPHAGITISPUDBILIARY DISEASE
AUTONOMICDISTURBANCES
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MIMI
CHEST PAIN CHEST PAIN ANXIETYANXIETYFEAR OF IMPENDING DEATHFEAR OF IMPENDING DEATHBREATHLESSNESSBREATHLESSNESSVOMITINGVOMITINGCOLLAPSECOLLAPSESYNCOPESYNCOPESILENTSILENT
SEVERELASTS LONGER THAN ANGINAL PAINTIGHTNESSHEAVINESSCONSTRICTION IN NECK
SYMPTOMS
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MYOCARDIAL INFARCTIONMYOCARDIAL INFARCTIONSIGNSSIGNS
SIGNS OF SYMPATHETIC ACTIVATIONSIGNS OF SYMPATHETIC ACTIVATIONPALLORPALLOR
SWEATINGSWEATING
TACHYCARDIATACHYCARDIA
SIGNS OF VAGAL STIMULATIONSIGNS OF VAGAL STIMULATIONVOMITINGVOMITING
BRADYCARDIABRADYCARDIA
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MYOCARDIAL INFARCTIONMYOCARDIAL INFARCTIONSIGNSSIGNS
SIGNS OF IMPAIRED MYOCARDIAL FUNCTIONSIGNS OF IMPAIRED MYOCARDIAL FUNCTIONHYPOTENSIONHYPOTENSIONOLIGURIAOLIGURIACOLD PERIPHERIESCOLD PERIPHERIESNARROW PULSE PRESSURENARROW PULSE PRESSURERAISED JVPRAISED JVPS3S3QUIET S1QUIET S1DIFFUSE APICAL IMPULSEDIFFUSE APICAL IMPULSELUNG CREPTSLUNG CREPTS SIGNS OF TISSUE DAMAGE-------FEVERSIGNS OF TISSUE DAMAGE-------FEVER SIGNS OF COMPLICATIONS----MR,,,,,,,PERICARDITISSIGNS OF COMPLICATIONS----MR,,,,,,,PERICARDITIS
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MIMIINVESTIGATIONSINVESTIGATIONS
ECG HELPFUL ECG HELPFUL DIFFICULT INTERPRETATION IN PREVIOUS MI DIFFICULT INTERPRETATION IN PREVIOUS MI
PATIENTS AND OLD BBBPATIENTS AND OLD BBB RARELY NORMAL ECGRARELY NORMAL ECG IN 1/3 OF MI CASES INITIAL CHANGES MAY NOT BE IN 1/3 OF MI CASES INITIAL CHANGES MAY NOT BE
DIAGNOSTICDIAGNOSTIC EARLIEST CHANGE ST ELEVATIONEARLIEST CHANGE ST ELEVATION LATER R WAVE SIZE DIMINUTIONLATER R WAVE SIZE DIMINUTION Q WAVES IN TRANSMURAL MIQ WAVES IN TRANSMURAL MI T WAVE INVERSIONT WAVE INVERSION CHEK AREA OF INFARCTIONCHEK AREA OF INFARCTION
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MIMIINVESTIGATIONSINVESTIGATIONS
PLASMA BIOCHEMICAL MARKERS PLASMA BIOCHEMICAL MARKERSCK-MBCK-MBTROPONIN T & ITROPONIN T & I
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MIMIINVESTIGATIONSINVESTIGATIONS
FBC FBC LEUCOCYTOSIS ON 1LEUCOCYTOSIS ON 1STST. DAY. DAY
ESRESR RAISED RAISED
CRPCRP ELEVATED ELEVATED
CXR CXR PUMONARY EDEMA,,,CARDIOMEGALYPUMONARY EDEMA,,,CARDIOMEGALY ECHOECHO
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Clinical Spectrum of Acute Coronary Clinical Spectrum of Acute Coronary SyndromesSyndromes
Evidence of necrosis None Positive Positive
ECG earlyST-segment depression
and/orT-wave inversion
ST-segment elevation
ECG late No Q No Q Q develops
Stable Stable anginaangina
UnstableUnstableanginaangina
Non-STE MINon-STE MI STE MISTE MI
Antman EM. In: Braunwald E, ed. Heart Disease: A Textbook in Cardiovascular Medicine, 5th ed. Philadelphia, Pa: WB Saunders; 1997.
ST-segment depression
and/or T-wave inversion
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Acute Coronary SyndromesAcute Coronary Syndromes
Similar pathophysiologySimilar pathophysiology
Similar presentation and Similar presentation and early management rulesearly management rules
STEMI requires evaluation STEMI requires evaluation for acute reperfusion for acute reperfusion interventionintervention
Unstable AnginaUnstable Angina
Non-ST-Segment Non-ST-Segment Elevation MI Elevation MI (NSTEMI)(NSTEMI)
ST-Segment ST-Segment Elevation MI Elevation MI (STEMI)(STEMI)
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Diagnosis of Acute MIDiagnosis of Acute MI STEMI / NSTEMI STEMI / NSTEMI
At least 2 of the At least 2 of the followingfollowing
Ischemic symptomsIschemic symptomsDiagnostic ECG Diagnostic ECG
changeschangesSerum cardiac Serum cardiac
marker elevationsmarker elevations
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Diagnosis of Unstable AnginaDiagnosis of Unstable Angina
Patients with typical angina - An episode of angina Patients with typical angina - An episode of angina Increased in severity or durationIncreased in severity or durationHas onset at rest or at a low level of exertionHas onset at rest or at a low level of exertionUnrelieved by the amount of nitroglycerin or rest that Unrelieved by the amount of nitroglycerin or rest that
had previously relieved the painhad previously relieved the pain
Patients not known to have typical anginaPatients not known to have typical anginaFirst episode with usual activity or at rest within the First episode with usual activity or at rest within the
previous two weeksprevious two weeksProlonged pain at restProlonged pain at rest
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ACS Clinical PresentationACS Clinical Presentation Substernal chest pain or pressure (>20-30 Substernal chest pain or pressure (>20-30
min)min) Localization or radiation to arms, back, Localization or radiation to arms, back,
throat, jawthroat, jaw Accompanying featuresAccompanying features
DyspneaDyspneaNausea/vomitingNausea/vomitingDiaphoresisDiaphoresisWeaknessWeakness
Atypical: syncope, CVA, DKAAtypical: syncope, CVA, DKA
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Unstable Unstable AnginaAngina STEMISTEMI NSTEMINSTEMI
Non occlusive thrombus
Non specific ECG
Normal cardiac enzymes
Occluding thrombus sufficient to cause tissue damage & mild myocardial necrosis
ST depression +/- T wave inversion on ECG
Elevated cardiac enzymes
Complete thrombus occlusion
ST elevations on ECG or new LBBB
Elevated cardiac enzymes
More severe symptoms
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ECG assessmentECG assessment
ST Elevation or new LBBBST Elevation or new LBBBSTEMISTEMI
Non-specific ECGNon-specific ECGUnstable AnginaUnstable Angina
ST Depression or dynamicST Depression or dynamicT wave inversionsT wave inversions
NSTEMINSTEMI
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Normal or non-diagnostic EKGNormal or non-diagnostic EKG
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ST Depression or Dynamic T wave ST Depression or Dynamic T wave InversionsInversions
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ST-Segment Elevation MIST-Segment Elevation MI
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New LBBBNew LBBB
QRS > 0.12 secL Axis deviationProminent R wave V1-V3Prominent S wave 1, aVL, V5-V6 with t-wave inversion
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Cardiac markersCardiac markers Troponin ( T, I)Troponin ( T, I)
Very specific and more Very specific and more sensitive than CKsensitive than CK
Rises 4-8 hours after Rises 4-8 hours after injuryinjury
May remain elevated May remain elevated for up to two weeksfor up to two weeks
Can provide Can provide prognostic informationprognostic information
Troponin T may be Troponin T may be elevated with renal dz, elevated with renal dz, poly/dermatomyositispoly/dermatomyositis
CK-MB isoenzymeCK-MB isoenzyme
Rises 4-6 hours after Rises 4-6 hours after injury and peaks at 24 injury and peaks at 24 hourshours
Remains elevated 36-48 Remains elevated 36-48 hourshours
Positive if CK/MB > 5% Positive if CK/MB > 5% of total CK and 2 times of total CK and 2 times normalnormal
Elevation can be Elevation can be predictive of mortalitypredictive of mortality
False positives with False positives with exercise, trauma, muscle exercise, trauma, muscle dz, DM, PEdz, DM, PE
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AORTIC DISSECTIONAORTIC DISSECTION
A BREACH IN INTEGRITY OF AORTIC A BREACH IN INTEGRITY OF AORTIC WALLWALL
ARTERIAL BLOOD BURSTS INTO ARTERIAL BLOOD BURSTS INTO MEDIA OF AORTAMEDIA OF AORTA
MEDIA SPLITS IN TWO LAYERS.MEDIA SPLITS IN TWO LAYERS.FALSE LUMEN ALONGSIDE A TRUE FALSE LUMEN ALONGSIDE A TRUE
LUMEN.LUMEN.DOUBLE-BARRELLED OR BILUMINAL DOUBLE-BARRELLED OR BILUMINAL
AORTA. AORTA.
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AORTIC DISSECTIONAORTIC DISSECTIONPREDISPOSING FACTORSPREDISPOSING FACTORS
HTNHTN AORTIC ATHEROSCLEROSISAORTIC ATHEROSCLEROSIS NON-SPECIFIC AORTIC ANEURYSMNON-SPECIFIC AORTIC ANEURYSM AORTIC COARCTATIONAORTIC COARCTATION COLLAGEN DISORDERS MARFANS SYND,,,E D COLLAGEN DISORDERS MARFANS SYND,,,E D
SYNDROMESYNDROME FIBROMUSCULAR DYSPLASIAFIBROMUSCULAR DYSPLASIA PREVIOUS AORTIC SURGERY CABG AV PREVIOUS AORTIC SURGERY CABG AV
REPLACEMENT REPLACEMENT PREGNANCY(3PREGNANCY(3RDRD, TRIMESTER), TRIMESTER) TRAUMATRAUMA IATROGENICIATROGENIC
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AORTIC DISSECTIONAORTIC DISSECTIONCLINICAL FEATURESCLINICAL FEATURES
TEARING PAINTEARING PAIN ABRUPT ONSTABRUPT ONST COLLAPSECOLLAPSE MARFAN`S SYNDROMEMARFAN`S SYNDROME PT APPEARS TO BE IN SHOCKPT APPEARS TO BE IN SHOCK BP---NORMAL OR RAISEDBP---NORMAL OR RAISED AC AR MAY DEVELOPAC AR MAY DEVELOP ASYMMETRY OF PULSESASYMMETRY OF PULSES MIMI PARAPLEGIA(SPINAL)PARAPLEGIA(SPINAL) ACUTE ACUTE
ABDOMEN(MESENTERIC ABDOMEN(MESENTERIC CAELIAC)CAELIAC)
RENAL FAILURERENAL FAILURE ACUTE LIMB ISCHEMIA(LEGS)ACUTE LIMB ISCHEMIA(LEGS)
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TENSION PNEUMOTHORAXTENSION PNEUMOTHORAX
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PNEUMOTHORAXPNEUMOTHORAX
PRESENCE OF AIR IN PLEURAL SPACEPRESENCE OF AIR IN PLEURAL SPACESPONTANEOUSSPONTANEOUS
PRIMARYPRIMARYSECONDARYSECONDARY
TRAUMATICTRAUMATICIATROGENICIATROGENIC
NON-IATROGENICNON-IATROGENIC
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PNEUMOTHORAXPNEUMOTHORAXCLINICAL FEATURESCLINICAL FEATURES
SUDDEN-ONSET UNILAT. CHEST PAINSUDDEN-ONSET UNILAT. CHEST PAIN BREATHLESSNESSBREATHLESSNESS ASYMPTOMATIC (NOT TENSION PNEUMOTHORAX)ASYMPTOMATIC (NOT TENSION PNEUMOTHORAX) DEC OR ABSENT BREATH SOUNDS DEC OR ABSENT BREATH SOUNDS (IF PNEUMOTHORAX (IF PNEUMOTHORAX
MORE THAN15%).MORE THAN15%).
RESONANT ON PERCUSSIONRESONANT ON PERCUSSION MEDIASTINAL DISPLACEMENT TO OPPOSITE SIDEMEDIASTINAL DISPLACEMENT TO OPPOSITE SIDE TACHYCARDIATACHYCARDIA HYPOTENSIONHYPOTENSION CYANOSISCYANOSIS TRACHEAL DISPLACEMENTTRACHEAL DISPLACEMENT
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TENSION PNEUMOTHORAXTENSION PNEUMOTHORAXDIAGNOSISDIAGNOSIS
CLINICALCLINICALCXRCXR
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PULMONARY EMBOLISMPULMONARY EMBOLISM
RISK FACTORS FOR THROMBOEMBOLISMRISK FACTORS FOR THROMBOEMBOLISM CLINICAL FEATURES DEPEND ON SIZE CLINICAL FEATURES DEPEND ON SIZE FAINTNESS OR COLLAPSEFAINTNESS OR COLLAPSE CENTRAL CHEST PAINCENTRAL CHEST PAIN APPREHENSIONAPPREHENSION SEVERE DYSPNOEASEVERE DYSPNOEA PLEURITIC PAINPLEURITIC PAIN HAEMOPTYSISHAEMOPTYSIS
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PULMONARY EMBOLISMPULMONARY EMBOLISMSIGNSSIGNS
MAJOR CIRCULATORY COLLAPSEMAJOR CIRCULATORY COLLAPSETACHYCARDIATACHYCARDIAHYPOTENSIONHYPOTENSIONINC JVPINC JVPRT.VENTRICULAR GALLOP RHYTHMRT.VENTRICULAR GALLOP RHYTHMSPLIT P2SPLIT P2SEVERE CYANOSISSEVERE CYANOSISDEC URINARY OUTPUT.DEC URINARY OUTPUT.
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PULMONARY EMBOLISMPULMONARY EMBOLISMINVESTIGATIONSINVESTIGATIONS
CXRCXRUSUALLY NORMALUSUALLY NORMALPULM;OPACITIESPULM;OPACITIESWEDGE-SHAPED OPACITYWEDGE-SHAPED OPACITYHORIZONTAL LINEAR OPACITIESHORIZONTAL LINEAR OPACITIESPLEURL EFFUSIONPLEURL EFFUSIONOLIGAEMIC LUNG FIELDSOLIGAEMIC LUNG FIELDSENLARGED PULMONARY ARTERYENLARGED PULMONARY ARTERYELEVATED DIAPHRAGM ELEVATED DIAPHRAGM
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PULMONARY EMBOLISMPULMONARY EMBOLISMINVESTIGATIONSINVESTIGATIONS
ECGECGS1S1Q3Q3T3T3RBBBRBBBSINUS TACHYSINUS TACHYRV HYPERTROPHYRV HYPERTROPHY
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PULMONARY EMBOLISMPULMONARY EMBOLISMINVESTIGATIONSINVESTIGATIONS
ABGs ABGsMAY BE NORMALMAY BE NORMAL
OROR
DEC;PaO2DEC;PaO2DEC;PaCO2DEC;PaCO2METABOLIC ACIDOSISMETABOLIC ACIDOSIS
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PULM; EMBOLISMPULM; EMBOLISMINVESTIGATIONSINVESTIGATIONS
D-DIMERD-DIMERVENTILATION-PERFUSION SCANNINGVENTILATION-PERFUSION SCANNINGCT PULMONARY ANGIOGRAPHYCT PULMONARY ANGIOGRAPHYMRIMRICOLLOR DOPPLERCOLLOR DOPPLERECHOECHO
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PLEURISYPLEURISY
ANY DISEASE PROCESS INVOLVING ANY DISEASE PROCESS INVOLVING PLEURA AND CAUSING PLEURITIC PLEURA AND CAUSING PLEURITIC PAINPAIN
COMMON FEATURE OF PULMONARY COMMON FEATURE OF PULMONARY INFECTION AND INFARCTIONINFECTION AND INFARCTION
MAY OCCUR IN MALIGNANCYMAY OCCUR IN MALIGNANCY
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PLEURISYPLEURISY
PLEURAL PAINPLEURAL PAIN RIB MOVEMENT RIB MOVEMENT
RESTRICTEDRESTRICTED PLEURAL RUBPLEURAL RUB H/O RESP ILLNESSH/O RESP ILLNESS CXRCXR
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TBTB
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CONNECTIVE TISSUE DISORDERS CAUSING CONNECTIVE TISSUE DISORDERS CAUSING CHEST PAINCHEST PAIN
RHEUMATOID ARTHRITISRHEUMATOID ARTHRITISSLESLESSSSDMSDMSPMSPMSRHEUMATIC FEVERRHEUMATIC FEVER
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CHEST MALIGNANCIESCHEST MALIGNANCIES
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RUPTURED OESOPHAGUSRUPTURED OESOPHAGUSCAUSESCAUSES
MOST COMMON IATROGENIC (ENDOSCOPIC MOST COMMON IATROGENIC (ENDOSCOPIC PERFORATION)PERFORATION)
MALINANCYMALINANCY CORROSIVE STRICTURES PERFORATIONCORROSIVE STRICTURES PERFORATION POST RADIOTHERY STRICTURESPOST RADIOTHERY STRICTURES PERFORATED PEPTIC ULCERPERFORATED PEPTIC ULCER SPONTANEOUS OESOPHAGEAL SPONTANEOUS OESOPHAGEAL
PERFORATION (BOERHAAVE SYNDROME)PERFORATION (BOERHAAVE SYNDROME)
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RUPTURED OESOPHAGUSRUPTURED OESOPHAGUSCLINICAL FEATURESCLINICAL FEATURES
SEVERE CHEST PAINSEVERE CHEST PAINSHOCKSHOCKSUB-CUTANEOUS EMPHYSEMASUB-CUTANEOUS EMPHYSEMAPLEURAL EFFUSIONPLEURAL EFFUSIONPNEUMOTHORAXPNEUMOTHORAXPNEUMOMEDIASTINUMPNEUMOMEDIASTINUM
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OESOPHAGEAL PAINOESOPHAGEAL PAIN
CAN MIMIC ANGINAL PAINCAN MIMIC ANGINAL PAINMAY GET PRECIPITATED BY MAY GET PRECIPITATED BY
EXERCISEEXERCISEMAY BE RELIEVED BY NITRATESMAY BE RELIEVED BY NITRATESRELATION WITH SUPINE RELATION WITH SUPINE
POSITION,EATING,DRINKINGPOSITION,EATING,DRINKING H/O REFLUXH/O REFLUXCAN RADIATE TO BACKCAN RADIATE TO BACK
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MYOCARDITISMYOCARDITISPERICARDITISPERICARDITIS
PAINPAIN ---- ----RETROSTERNAL OR IN THE SHOULDERRETROSTERNAL OR IN THE SHOULDER
INTENSITY--- INTENSITY--- VARIESVARIES IN WITH MOVEMENT AND IN WITH MOVEMENT AND PHASE OF RESPIRATIONPHASE OF RESPIRATION
SHARPSHARP --- ---PAIN MAY CATCH THE PATIENT DURING PAIN MAY CATCH THE PATIENT DURING COUGHING OR INSPIRATIONCOUGHING OR INSPIRATION
H/O PRODROMALH/O PRODROMAL VIRAL ILLNESSVIRAL ILLNESS DYSPNEADYSPNEA PERICARDIAL FRICTION RUBPERICARDIAL FRICTION RUB FEVERFEVER LEUCOCYTOSISLEUCOCYTOSIS
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ACUTE MYOCARDITISACUTE MYOCARDITIS
INFECTIOUSINFECTIOUS
TOXIN/ DRUG INDUCEDTOXIN/ DRUG INDUCED
IMMUNOLOGIC CAUSESIMMUNOLOGIC CAUSES
VIRALBACTRICKETTSIALSPIROCHETALFUNGALPARASITIC
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INFECTIOUS ACUTE MYOCARDITISINFECTIOUS ACUTE MYOCARDITIS
OFTEN FOLLOWS URTIOFTEN FOLLOWS URTI CHEST PAINCHEST PAIN S/O HEART FAILURES/O HEART FAILURE ECG SHOW ECG SHOW
NON-SPECIFIC NON-SPECIFIC ST-T CHANGES ST-T CHANGES CONDUCTION CONDUCTION DISTURBANCES DISTURBANCES VENTRICULAR VENTRICULAR ECTOPYECTOPY
CXR CARDIOMEGALYCXR CARDIOMEGALY
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PERICARDITISPERICARDITIS INFLAMMATORY INFLAMMATORY
VIRAL VIRAL TUBERCULAR TUBERCULAR BORRELIA BURGDORFERI(LYME DISEASE)BORRELIA BURGDORFERI(LYME DISEASE)
UREMIC PERICARDITISUREMIC PERICARDITIS NEOPLASTICNEOPLASTIC POST MI OR POST CARDIOTOMY DRESSLER`S POST MI OR POST CARDIOTOMY DRESSLER`S
SYNDROMESYNDROME RADIATIONRADIATION SLESLE RARA DRUG-INDUCEDDRUG-INDUCED MYXEDEMAMYXEDEMA
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PERICARDITISPERICARDITISSYMPTOMSSYMPTOMS
PAINPAIN ---- ----RETROSTERNAL OR IN THE SHOULDERRETROSTERNAL OR IN THE SHOULDER
INTENSITY--- INTENSITY--- VARIESVARIES IN WITH MOVEMENT AND IN WITH MOVEMENT AND PHASE OF RESPIRATIONPHASE OF RESPIRATION
SHARPSHARP --- ---PAIN MAY CATCH THE PATIENT DURING PAIN MAY CATCH THE PATIENT DURING COUGHING OR INSPIRATIONCOUGHING OR INSPIRATION
H/O PRODROMALH/O PRODROMAL VIRAL ILLNESSVIRAL ILLNESS DYSPNEADYSPNEA PERICARDIAL FRICTION RUBPERICARDIAL FRICTION RUB FEVERFEVER LEUCOCYTOSISLEUCOCYTOSIS
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PERICARDITISPERICARDITIS
ECG
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PERICARDITISPERICARDITIS
CXR IN CXR IN PERICARDITISPERICARDITIS
SHOWS FLUID SHOWS FLUID COLLECTIONCOLLECTION
MAY BE DRYMAY BE DRY ECHO ADVISEDECHO ADVISED
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MITRAL VALVE PROLAPSEMITRAL VALVE PROLAPSE
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MITRAL VALVE PROLAPSEMITRAL VALVE PROLAPSE SHARP LEFT SIDED CHEST PAINSHARP LEFT SIDED CHEST PAIN DYSPNEADYSPNEA FATIGUEFATIGUE PALPITATIONPALPITATION FEMALESFEMALES THINTHIN CHEST WALL DEFORMITIESCHEST WALL DEFORMITIES MID-SYSTOLIC CLICKSMID-SYSTOLIC CLICKS ECHOECHO CARDIAC CATHCARDIAC CATH
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MUSCULOSKELETAL CHEST MUSCULOSKELETAL CHEST PAINPAIN
VARY WITH VARY WITH POSTUREPOSTURE
VARY WITH VARY WITH POSITIONPOSITION
LOCAL LOCAL TENDERNESSTENDERNESS
ARTHRITISARTHRITIS COSTOCONDRITISCOSTOCONDRITIS INTERCOSTAL INTERCOSTAL
MUSCLE INJURYMUSCLE INJURY COXSACKIE VIRAL COXSACKIE VIRAL
INFECTIONINFECTION MINOR SOFT MINOR SOFT
TISSUE INJURIESTISSUE INJURIES
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OSTEOARTHRITISOSTEOARTHRITIS
Localized DIS.Localized DIS. KNEE OR HIP KNEE OR HIP
INVOLVEMEMENT IS INVOLVEMEMENT IS COMMONCOMMON
PAIN ON PAIN ON MOVEMENTMOVEMENT
CREPITUSCREPITUS WORSE AT END OF WORSE AT END OF
DAYDAY TENDER JT.TENDER JT.
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TEITZE`S SYNDROMETEITZE`S SYNDROMEIDIOPATHIC COSTOCONDRITISIDIOPATHIC COSTOCONDRITIS
LOCALIZED PAIN/TENDERNESS AT LOCALIZED PAIN/TENDERNESS AT COSTOCONDRAL JUNCTIONCOSTOCONDRAL JUNCTION
ENHANCED BY ENHANCED BY EMOTION,COUGHING,SNEEZINGEMOTION,COUGHING,SNEEZING
2nd.RIB MOST AFFECTED2nd.RIB MOST AFFECTED
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PROLAPSED DISCPROLAPSED DISC
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HERPES ZOSTER HERPES ZOSTER
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THANK YOU