Acute coronary syndrome resident survival guide

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Patient Presentation

Common presentation

Initial Evaluation and Orders

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 (pleurtic and pericarditis chest pain worsens with respiration) and relieving factors (relieved by nitrates), 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.

Physical Examination

  • General
    • Check for alertness, and orientation with time, place, and person
    • Patient leaning forward can point towards pericarditis
  • Cardiovascular:
    • Pulse Rate (rate, rhythm. volume, quality, symmetry, all 4 limbs. Aortic dissection- Diminution or absence of pulses)
    • Blood pressure (check for symmetry in all the limbs)
    • Auscultate carotid artery (check for bruit)
    • Jugular venous distension, check for hepatojugular reflex
    • Inspection: Check for displacement of the apex
    • Palpation: Confirm the findings of inspection (cardiac apex), musculo-skeletal tenderness, crepitus (esophageal rupture,subcutaneous emphysema), feel for any thrill (possible regurgitation), heave (right ventricular hypertrophy)
    • Auscultation:

Differential Diagnosis

EKG findings

Electrocardiogram in Unstable angina / NSTEMI

The resting electrocardiogram in the patient with unstable angina / non ST elevation MI may show any of the following:


ST Depression in a patient with unstable angina

Electrocardiogram in STEMI

The electrocardiographic definition of ST elevation MI requires the following: at least 1 mm (0.1 mV) of ST segment elevation in 2 or more anatomically contiguous leads.[1] While these criteria are sensitive, they are not specific as thromboctic coronary occlusion is not the most common cause of ST segment elevation in chest pain patients.[2]

Chest Xray Findings

Aortic dissection

  • Increased aortic diameter
  • Widened mediastinum
  • Pleural effusion (hemothorax) in the absence of CHF

2. Pulmonary Embolism

  • 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.
  1. Smith SW, Whitwam W (2006). "Acute coronary syndromes". Emerg. Med. Clin. North Am. 24 (1): 53–89, vi. doi:10.1016/j.emc.2005.08.008. PMID 16308113. Unknown parameter |month= ignored (help)