✅Approach to the Chest pain

‼️تنطیمات دستگاه ECG: باید روی سرعت 25mm/sec و ولتاژ 10mm/mv باشه.

• ECG

🔹اول قراره درباره‌ی اپروچ کلی به درد قفسه‌ی سینه صحبت کنیم، و در پار‌ت‌های بعدی بطور اسپیسیفیک درباره‌ی ACS.

▪️Life-threatening causes:

•Acute coronary syndrome (ACS)
•Acute aortic dissection
•Pulmonary embolism
•Tension pneumothorax
•Pericardial tamponade
•Mediastinitis (eg, esophageal rupture)
•Myocarditis
•Stress (takotsubo) cardiomyopathy
•Perforated peptic ulcer

▫️In general, it is safest to assume an ED patient with chest pain and any of the following has a lifethreatening condition until proven otherwise:

•Abnormal vital signs
•Obvious distress
•Signs of hypoperfusion (eg, diaphoresis, cool/clammy skin)
•Abrupt onset of thoracic or abdominal pain with a sharp, tearing, and/or ripping character
•Variation in pulse (absence of a proximal extremity or carotid pulse) and/or blood pressure
(>20 mmHg difference between the right and left arm)
•ECG with ST-segment elevation

▪️"Atypical" symptoms (eg, dyspnea, nausea, weakness)

Females are more likely to have associated dyspnea than males, and patients who are older or have diabetes are more likely to present with dyspnea without chest pain

▪️Aortic dissection:

most commonly affects patients with systemic hypertension in their seventh decade of life, but it can affect younger individuals, particularly those with known aortic valve or connective tissue abnormalities.

▪️Location

Nonpositional and nonreproducible – Angina is a constant discomfort that does not change with respiration or with most changes in position (one exception is lying down, which increases venous
return). It is also not provoked or worsened with palpation of the chest wall. However, the presence
of a change in pain with respiration (or position) or pain elicited by palpation does not exclude
angina as the cause.

▪️Postprandial pain

is generally considered to be gastrointestinal in origin. However, it may also be
anginal, especially in patients with severe ischemia (eg, left main or three-vessel coronary disease)

▪️Relief of chest discomfort with nitroglycerin

🔺️Relief of chest discomfort with nitroglycerin is not specific for angina, since a similar response may be seen with esophageal spasm or other gastrointestinal problems, as nitroglycerin also relaxes smooth muscle.

▫️Ischemic pain does not change with respiration or position. It may or may not respond to nitroglycerin.

▪️ECG and Trop

🔺Clinicians must be aware that the initial ECG is often not diagnostic in patients with ACS. 41% of patients with (NSTEMI) do not have the typical STdepression or T-wave inversion.
▫️The ECG should also be repeated if the initial ECG is not diagnostic but the patient remains symptomatic and there remains high clinical suspicion for AMI.
▫️The ECG must be interpreted in combination with the patient's signs and symptoms since many ECG findings are not specific

🔺a single set of negative cardiac biomarkers is not sufficient to rule out AMI

▪️Symptoms commonly associated with noncardiac syndromes

•Pleuritic pain, sharp or knife-like pain related to respiratory movements or cough
•Primary or sole location in the mid or lower abdominal region
•Any discomfort localized with one {nger
•Any discomfort reproduced by movement or palpation
•Constant pain lasting for days
•Fleeting pains lasting for a few seconds or less
•Pain radiating into the lower extremities or above the mandible

▪️یه‌ سری نکات تکمیلی هم در اوردر نوشته شده است.

▪️تصاویر هم مهم هستند.