SimWars 2021-22

Chest Pain
Disclaimer

? The views expressed at this meeting/presentation, are the

views and ideas of the said individual/s only. They do not
necessarily represent the views, beliefs or attitudes of the
Royal College of Surgeons in Ireland (RCSI). In addition,
the referral to any products, services, directions or advice
by any parties at this event, does not necessarily
constitute an endorsement of any kind by the RCSI.
Chest Pain: Common Causes

● Acute Coronary Syndrome

● Pulmonary Embolism
● Pneumothorax
● Pneumonia
● Esophagitis
● Musculoskeletal
Chest Pain: Rare Causes

● Aortic Dissection
● Pancreatitis
● Cholecystitis
● Esophageal Rupture
● Pericarditis
Secondary Survey: Mnemonics

● O: Onset ● S: Signs/Symptoms
● P: Provocation/Palliation ● A: Allergies
● Q: Quality ● M: Medications
● R: Radiation ● P: Past Medical History
● S: Severity ● L: Last Oral Intake
● T: Time ● E: Events
Secondary Survey: Respiratory

● Inspect the Airway

● Inspect the Chest
● Palpate the Chest
● Auscultate the Chest
● Percuss the Chest
● pH
● ABG/VBG
● Chest X-Ray
Secondary Survey: Cardiovascular

● Inspect the Chest

● Palpate Pulses
● Auscultate Heart Sounds
● Auscultate Lungs
● Inspect Feet/Sacrum
● ECG (4- and 12-Lead)
● FBC
● Cardiac Enzymes
● Chest X-Ray
● Echocardiogram
Common
Acute Coronary Syndrome (ACS)

● Rupture of coronary artery plaque causing myocardial

ischaemia.

● Unstable Angina
● NSTEMI
● STEMI
ACS: Characteristics

● Constant Pain
● Central
● “Crushing”
● Risk Factors ● Elevated Troponin
● Associated Symptoms: ● ST-Segment Elevation
○ Shortness of Breath
○ Diaphoresis
○ Nausea
ACS: Diagnostics

● ECG
● Troponin
● PCI
ACS: Treatment

● Oxygen: Titrate to SpO2 90-94%

● Aspirin: 300mg PO
● Ticagrelor: 180mg PO
● Morphine: 0.1mg/kg IV
● Nitroglycerin (GTN): 0.4mg SL
○ Blood Pressure Systolic >100
○ No PDE-5 Inhibitors
○ No Evidence of Right Sided MI
● Call Cardiology
○ PCI Lab
● Consider Beta Blocker
Pulmonary Embolism (PE)

● Embolus that travels to and occludes the pulmonary

circulation.
PE: Characteristics

● Shortness of Breath
● Pleuritic Chest Pain
● Risk Factors
○ Periods of Inactivity
● Signs/Symptoms of DVT
Pneumothorax

● Build up of air in the thoracic cavity, outside the lungs.

Pneumothorax: Characteristics

● Shortness of Breath
● Pleuritic Chest Pain
● Risk Factors:
○ Tall, Thin Males
Pneumonia

● Infection in the lower respiratory tract that causes

inflammation in the alveoli.
Pneumonia

● Fever
● Cough
● Pleuritic Chest Pain
● Shortness of Breath
Esophagitis

● Irritation or inflammation of the esophagus, usually due to

reflux of gastric acid.
Esophagitis

● Chest Pain
● “Burning”
● Comes and Goes
● Associated with Meals
● Associated with Lying Down
Musculoskeletal Chest Pain

● Pain caused by sprain/strain of muscle or local inflammation.

Musculoskeletal: Characteristics

● Chest Pain
● Changes with Movement
Rare
Aortic Dissection

● Splitting of the muscular layers of the aorta.

Aortic Dissection: Characteristics

● Constant Pain
● Central
● “Tearing”
● Risk Factors: ● Asymmetry or Absence of
○ Hypertension Pulses
○ Collagen Disorders ● Abnormal Chest X-Ray
○ Bicuspid Aortic Valve ○ Widened Mediastinum
● Associated Symptoms: ● CT Angiography
○ Shortness of Breath
○ Diaphoresis
○ Nausea
Aortic Dissection: Diagnostics

● ECG
● Chest X-Ray
● CT Aortogram
Aortic Dissection: Treatment

● Oxygen: Titrate to SpO2 90-94%

● Morphine: 0.1mg/kg IV
● Call Cardiology
● Control Blood Pressure
● Surgery?
Pancreatitis

● Inflammation of the pancreas.

Pancreatitis: Characteristics

● Constant Pain
● Epigastric
● Radiating to the Back
● Nausea
● Vomiting
● Risk Factors:
○ Alcohol
○ Infection
○ Drugs
Cholecystitis

● Inflammation of the gallbladder.

Cholecystitis: Characteristics

● Constant Pain
● Right Hypochondrium
● Murphy’s Sign
● Nausea
● Vomiting
Esophageal Rupture

● Does what it says on the box.

Esophageal Rupture: Characteristics

● Chest Pain
● Signs of shock
● Subcutaneous emphysema
Pericarditis

● Inflammation of the lining around the heart.

Pericarditis: Characteristics

● Chest Pain
○ Sharp
● Friction Rub (Auscultation)
○ Central
● Diffuse ST Segment Changes
○ Worse on Inspiration
● Signs on Echocardiogram
○ Relieved by Leaning Forward
● Fever (Sometimes)
Pericarditis: Diagnostics

● ECG
● Chest X-Ray
● Echocardiogram
Pericarditis: Treatment

● Depends on Cause
● Viral/Idiopathic:
○ Advise rest
○ NSAIDs
● Bacterial
○ Antibiotics (Local Guidelines)
● High Risk:
○ Cardiology
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