34 min

Chest pain Ward Calls

    • Medicine

Sam speaks to Dr Adele Pope, advanced cardiology trainee at Auckland Hospital, about how to attack the most common, and often the most uncertain, ward call.

Differential



* Life threatening



* ACS

* PE

* Dissection

* Cardiac tamponade

* Pneumonia

* Pneumothorax

* Oesophageal bleed





* Heart



* Pericarditis





* Lungs



* Mechanical (foreign body, surgical, chest drain, post-pleurocentesis)





* Oesophagus



* Reflux

* Oesophagitis

* Oesophageal spasm





* MSK



* Musculoskeletal

* Costochondritis

* Rib fracture





* Below the chest



* Upper abdominal pain





* Above the chest



* Anxiety







Approach



* Eyeball the patient

* ABCs



* Calling a code



* 777 (or your local hospital emergency number)

* This is Sam, medical house officer. I need the adult resus team to attend North Shore Hospital, ward 10, room E3.









* History



* SOCRATES (site, onset, character, radiation, associated symptoms, timing, exacerbating factors, severity)

* Previous similar episodes? History of exertion chest pain?

* Diaphoresis

* Shortness of breath

* Review of systems





* Identify risk factors

* Vitals + Examination



* General inspection + peripheries

* Aiming to identify red flags of hypotension, reproducibility on palpation and respiratory issues

* Abdomen, calves, catheter and drains (for completeness)





*  ECG



* Take your time and be systematic

* Look at an old ECG

* Ischaemic ECG defined as STEMI, or any T wave inversion, ST depression, Q waves.

* Look for contiguous and reciprocal abnormalities.

* T wave change normal variants occur in III, aVR, V1.

* A repeat ECG in 15 minutes is useful to identify dynamic changes.





* Consider investigations



* FBC, U&E, troponin

* CXR if failure or respiratory issues are within your differential (not so useful for ACS, but unlikely to harm)





* Management



* Call for help (code or at least registrar support)

* Attach continuous monitoring e.g. defibrillator pads

* Re-assess stability of the patient

* Oxygen only if hypoxic

* GTN spray

* Opiate analgesia (IV morphine boluses ideally)

* Determine bleeding risk



* Identify any anti-platelet and anti-coagulation medicines in use

* Post-operative status

* Consider loading with aspirin 300 mg PO









* Document



* Review past notes

* Basics (date/time/name/reason for review)

* Positives and pertinent negatives

* Impression and differential with justification. Have you eliminated life threatening conditions?

* Consider TIMI or HEART score (acknowledging use outside of ED)

* Clear and specific plan

* Consider discussion with senior and escalation, especially if called back to patient again









Specificity of chest pain symptoms and examination findings [Evidence]

Fanaroff AC, Rymer JA, Goldstein SA, Simel DL, Newby LK. Does This Patient With Chest Pain Have Acute Coronary Syndrome?The Rational Clinical Examination Systematic Review. JAMA. 2015;314(18):1955–1965. doi:10.1001/jama.2015.12735



* No single finding rules in or rules out acute coronary syndrome.

* The most specific (convincing) symptoms of ACS were:



* Pain radiation to both arms (specificity, 96%; LR, 2.6 [95% CI, 1.8-3.7]).

Sam speaks to Dr Adele Pope, advanced cardiology trainee at Auckland Hospital, about how to attack the most common, and often the most uncertain, ward call.

Differential



* Life threatening



* ACS

* PE

* Dissection

* Cardiac tamponade

* Pneumonia

* Pneumothorax

* Oesophageal bleed





* Heart



* Pericarditis





* Lungs



* Mechanical (foreign body, surgical, chest drain, post-pleurocentesis)





* Oesophagus



* Reflux

* Oesophagitis

* Oesophageal spasm





* MSK



* Musculoskeletal

* Costochondritis

* Rib fracture





* Below the chest



* Upper abdominal pain





* Above the chest



* Anxiety







Approach



* Eyeball the patient

* ABCs



* Calling a code



* 777 (or your local hospital emergency number)

* This is Sam, medical house officer. I need the adult resus team to attend North Shore Hospital, ward 10, room E3.









* History



* SOCRATES (site, onset, character, radiation, associated symptoms, timing, exacerbating factors, severity)

* Previous similar episodes? History of exertion chest pain?

* Diaphoresis

* Shortness of breath

* Review of systems





* Identify risk factors

* Vitals + Examination



* General inspection + peripheries

* Aiming to identify red flags of hypotension, reproducibility on palpation and respiratory issues

* Abdomen, calves, catheter and drains (for completeness)





*  ECG



* Take your time and be systematic

* Look at an old ECG

* Ischaemic ECG defined as STEMI, or any T wave inversion, ST depression, Q waves.

* Look for contiguous and reciprocal abnormalities.

* T wave change normal variants occur in III, aVR, V1.

* A repeat ECG in 15 minutes is useful to identify dynamic changes.





* Consider investigations



* FBC, U&E, troponin

* CXR if failure or respiratory issues are within your differential (not so useful for ACS, but unlikely to harm)





* Management



* Call for help (code or at least registrar support)

* Attach continuous monitoring e.g. defibrillator pads

* Re-assess stability of the patient

* Oxygen only if hypoxic

* GTN spray

* Opiate analgesia (IV morphine boluses ideally)

* Determine bleeding risk



* Identify any anti-platelet and anti-coagulation medicines in use

* Post-operative status

* Consider loading with aspirin 300 mg PO









* Document



* Review past notes

* Basics (date/time/name/reason for review)

* Positives and pertinent negatives

* Impression and differential with justification. Have you eliminated life threatening conditions?

* Consider TIMI or HEART score (acknowledging use outside of ED)

* Clear and specific plan

* Consider discussion with senior and escalation, especially if called back to patient again









Specificity of chest pain symptoms and examination findings [Evidence]

Fanaroff AC, Rymer JA, Goldstein SA, Simel DL, Newby LK. Does This Patient With Chest Pain Have Acute Coronary Syndrome?The Rational Clinical Examination Systematic Review. JAMA. 2015;314(18):1955–1965. doi:10.1001/jama.2015.12735



* No single finding rules in or rules out acute coronary syndrome.

* The most specific (convincing) symptoms of ACS were:



* Pain radiation to both arms (specificity, 96%; LR, 2.6 [95% CI, 1.8-3.7]).

34 min

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