Acute coronary syndrome resident survival guide

Patient Presentation

Common presentation

• Substernal/precordial chest pressure/heaviness/pain
• Pain radiation to shoulder or arm/neck/jaw
• Nausea and/or vomiting
• Shortness of breath
• Diaphoresis
• Heartburn/ burning sensation in chest
• Dizziness
• Palpitations
• Near syncope / Syncope

Initial Evaluation and Orders

• Ensure patency of airway, check for adequate breathing and circulation.
• Vital signs (Heart rate, blood pressure, respiratory rate, temperature, oxygen saturation)
• 12-lead EKG (compare with old EKG if possible)
• Cardiac enzymes (three sets of troponin, CK, CK-MB at six hour intervals; first set may be normal, but order all three sets)
• Chest x-ray
• Oxygen (titrate for oxygen saturation levels >92%)
• IV access
• 325mg non-enteric coated aspirin by mouth (or per rectum if patient cannot take orally)
• If patient is not hypotensive and inferior myocardial infarction has been ruled out by EKG, give 0.4mg nitroglycerin sublingually up to three times, at 5 minute intervals, until chest pain improves.

Important!
Follow up with all pending tests and lab results as soon as these become available. For information on evaluating the results go to the apppropriate section on this page.

History and Symptoms

History of Present Illness:

• Chest pain history; ask about onset, duration, nature, intensity, location, progression, radiation (to arm, neck, jaw= acute coronary syndrome, or back=aortic dissection), aggravating and relieving factors, constant or intermittent.
• Ask if pain is associated with (head to toe). Headache, confusion, fever, photophobia, vision changes, bleeding, nausea, vomiting, apetite, weight loss, shortness of breath, palpitations, cough, sputum, abdominal pain, bowel symptoms, urinary symptoms.

1. Aortic Dissection

• • Diminution or absence of pulses in 40% of case
  • Coma, altered mental status, Cerebrovascular accident (CVA) and vagal episodes are seen in up to 20%
  • Descending dissection can lead to splanchnic ischemia, renal insufficiency, lower extremity ischemia or pulse deficits or focal neurologic deficits due to spinal cord ischemia.

• Chest X-Ray Abnormalities Include:

  • An increased aortic diameter is the most common CXR finding, seen in up to 84% of patients.
  • A widened mediastinum is the next most common finding, seen in 15-20%.
  • Normal in 17%.
  • Pleural effusion (hemothorax) in the absence of CHF can also be another clue to dissection.

• Next Study to Do:

  • MRI is currently thought to be the most sensitive noninvasive method of making the diagnosis of aortic dissection. As with CT, the diagnosis is made upon visualization of a double lumen with a visible flap. Sensitivity and specificity are both thought to be 98%, and the site of entry can be visualized in 85% of cases.

2. Pulmonary Embolism

• Supportive symptoms include:

  • Shortness of breath
  • Chest pain
  • Dyspnea
  • Anxiety
  • Pleuritic chest pain

• Supportive laboratory studies include:

  • D-dimers are formed by the degradation of fibrin clot.
  • Almost all patients with PE have some endogenous fibrinolysis, and therefore have elevated levels of D-dimer.
  • Many other processes, such as pneumonia, congestive heart failure (CHF), myocardial infarction (MI), malignancy, and surgery, are also associated with a mild degree of fibrinolysis, and hence an elevated D-dimer is not specific for pulmonary embolism.
  • Its negative predictive value, however, is 91 – 94%

• Next study to do:

  • Spiral CT scanning is now a standard modality to non-invasively diagnose PE.
  • Initial studies reported sensitivities for diagnosing emboli to the segmental level (4th order branch) as high as 98%

3. Tension Pneumothorax

• Supportive signs and symptoms include"

  • Sudden shortness of breath, cyanosis (turning blue) and pain felt in the chest and/or back are the main symptoms.
  • In penetrating chest wounds, the sound of air flowing through the puncture hole may indicate pneumothorax, hence the term "sucking" chest wound.
  • The flopping sound of the punctured lung is also occasionally heard.
  • Spontaneous pneumothoraces are reported in young people with a tall stature. As men are generally taller than women, there is a preponderance among males.
  • Pneumothorax can also occur as part of medical procedures, such as the insertion of a central venous catheter (an intravenous catheter) in the subclavian vein or jugular vein. While rare, it is considered a serious complication and needs immediate treatment. Other causes include mechanical ventilation, emphysema and rarely other lung diseases (pneumonia).

4. Esophageal Rupture

• Supportive signs and symptoms include:

  • The classic Meckler's triad of symptoms includes vomiting, lower chest pain, and cervical subcutaneous emphysema following overindulgence in food or alcohol, but is observed in only half of the cases.
  • The most common chest radiograph findings in spontaneous esophageal rupture (SER) are pleural effusion (91%) and pneumothorax (80%).
  • The initial sign on a plain film may be pneumomediastinum or subcutaneous emphysema.
  • Up to 12% of patients with SER may have a normal chest radiograph.

• Next study to do:

  • Contrast-enhanced esophageal radiography is diagnostic in 75% to 85% of cases.