CHEST PAIN - Stroke

 Quick guide to important ED Differentials of Chest Pain Acute Coronary Syndrome   Patient with central chest wall heaviness/ dyspnoea/ giddiness/ ghabrahat/syncope  Associated sweating, nausea, vomiting  Exertional symptoms  Radiation anywhere from jaw to epigastrium or either arms  ECG:  New ST/T changes OR conduction blocks  STEMI: ST elevation of minimum 1mm in contiguous leads except in v2,v3 > 1.5 mm (F) ; > 2mm (M) ST elevation II,III, aVF: Inferior wall STEMI STE V1-V4 : Anterior wall STEMI STE  I, aVL, V5, V6 : Lateral wall STEMI NSTEMI New onset ST elevation, depression or T inversion (not fitting into above criteria) Or elevated Troponin I Unstable angina Typical angina symptoms lasting for > 20 minutes, crescendo pattern with no new ECG changes and NO troponin elevation Troponin elevation > 99 percentile (see reference value as per the test) ECHO: RWMA (regional wall motion abnormality) Expedite initial treatment : ECG within 10 mins Window period : 6-12 hours Aortic Dissection  Sudden onset chest pain radiating to back  (inter scapular region)  Chest pain plus syndrome ( chest pain with limb weakness, chest pain with stroke, limb ischemia)  BP/Pulse deficit in two limbs   h/o Hypertension/ previous aortic disorders  Diagnosis : CT Aortogram Bourhaave Syndrome  Spontaneous oesophageal rupture  Sudden onset sharp substernal pain  h/o severe retching, vomiting or manoeuvres with sudden negative intrathoracic pressure  Tachycardia, dyspnoea, sweating, Fever  Hamman’s crunch (audible crepitus with heart beat) – rare finding on examination  Pneumothorax, Pneumomediastinum, Pleural effusion, subcutaneous emphysema  Diagnosis: CECT thorax with oral contrast Management of the below diagnoses have been explained briefly in the section on Dyspnoea Page 11-13 Massive Pulmonary Embolism  Patient with recent surgery, limb immobilisation, Deep vein thrombosis, limb swelling or Malignancy  Sudden onset breathlessness/ chest pain/syncope  Hypoxia with clear chest on auscultation/POCUS ECG: Sinus tachycardia, T inversion in V1,V2,V3 or inferior chest leads, S1Q3T3 sign ECHO: RA/RV dilatation or RV dysfunction  Cardiac Tamponade  H/O trauma, mediastinal or lung malignancy, CKD, TB/ recent MI  Raised JVP/ distended neck veins/ hypotension POCUS: circumferential fluid collection around the heart with RA/RV diastolic collapse  Get wide bore i.v. access & i.v. crystalloid bolus  Prepare for pericardiocentesis Tension Pneumothorax  h/o Trauma, COPD, Bullous lung disease, TB  Sudden onset SOB  Tracheal deviation, unilateral absence of breath sounds, hypotension, raised JVP, distended neck veins POCUS : Absent lung sliding (Barcode sign on M mode) Emergency treatment: Needle thoracentesis Lobar Pneumonia  H/O fever + chills, productive cough, pleuritic chest pain, haemoptysis  Fever, tachycardia, tachypnea, crepitation, decreased breath sounds POCUS: Focal B lines, Pleural shredding, hepatisation, syn-pneumonic effusion CXR: e/o lobar radio-opacity with air bronchogram, syn-pneumonic effusion 

Assessment of a patient with Suspected Stroke Salient history to be taken Salient clinical examination Point of care Investigation Basic initial management  Typical symptoms: FAST Facial deviation      (asymmetrical face while smiling/ clenching) Arm drift/limb weakness Speech abnormality (Slurring / aphasia) (Time to call SR neurology)  Atypical symptoms: numbness, dizziness/ vertigo, confusion/altered sensorium, visual disturbance, severe headache  Baseline neurological status, time last seen at normal/ at baseline  Onset & duration of symptoms  Progression or resolution of symptoms  Associated: headache, vomiting, seizure, incontinence   H/o trauma, intracranial  haemorrhage  Co-morbid illness: Diabetes, Hypertension, Coronary artery disease, Valvular heart disease, Chronic Kidney disease, Malignancy  Medication history: anticoagulants, any other medicines/ medicines given at referring facility  Check random blood sugar  Complete primary assessment  Document GCS and 3 Ps Pupil: size & reaction Power: B/L upper & lower limbs Plantar response   In case of ongoing vertigo /cerebellar symptoms, perform HINTS plus examination   RBS  Inform SR Neurology ASAP in suspected stroke after ruling out hypoglycaemia  CBC & Renal function Test  Coagulation profile  NCCT head  Stroke imaging  Rapid Antigen Test for COVID -19 (expedite for CT purpose)  ECG & Chest X-ray  - can be deferred till after CT  POC ECHO: If cardio-embolic stroke/ dissection is suspected   Blood gas ( if indicated in an unstable patient) *Always discuss with the Senior Resident on shift before proceeding with any of the following management   IV cannula: preferably in right arm (20G or larger)  If RBS < 70mg/dL  Inj. 50% dextrose 50 ml IV & reassess  Inform SR EM & SR Neurology ASAP & shift patient for CT  TARGETS TO ACHIEVE:  SR neurology review & NCCT head by 25 minutes of arrival (Always NCCT first to r/o haemorrhagic stroke)   Glucose = 140 - 180  BP < 185/110  Fibrinolytic therapy started by 60 minutes of arrival if eligible   Endovascular therapy by 6 hours of arrival if eligible