need help with ccs cases

Some info I found on the internet at WikiMD.org under CCS cases Location: Emergency room Vitals: Pulse: 80/min; B.P: 145/90 mm Hg; Temp: 98.8 F; R.R: 16/min; Height: 72 inches (180 cm); Weight: 72 Kg (158.4 lbs) . CC: Severe chest pain HPI: A 60-year old white male comes to E.R with a two- hour history of severe central chest pain that began while relaxing on the couch at home. The patient denies any exertional activity prior to the onset of symptoms. The pain is constant, 9/10 in severity, crushing in quality, and radiates to the left side of the jaw and left shoulder. There is associated nausea without vomiting. Over the past two months he has experienced several episodes of exertional chest pain while at work. The pain is usually relieved with rest. He did not seek any medical attention thinking that the pain was work related muscle spasms. Medical problems include hypertension for which he has been taking hydrochlorothiazide the past 10 years. He has no known allergies. FH: His father died of MI when he was 55. Mother is 85 yrs old and healthy. SH: He has been married for 34 years and has two sons. He is not sexually active. He has a 30-pack per year smoking history. He drinks moderate amounts of alcohol on weekends, but denies the use of recreational drugs. He is a truck driver. ROS: Denies headaches, vision changes, tinnitus, or vertigo. Denies muscle tenderness, joint pain, stiffness, or weakness. Rest of ROS is unremarkable. How to approach this case? This patient has come to the ED with chest pain of recent onset which has many causes and some of them may cause sudden death. Therefore, all such patients should be transported to ED immediately. Oxygen, IV access, cardiac monitoring, and EKG need to be done as soon as possible. Aspirin is given if MI is likely. Therefore, we should order the following: Order: Continuous supplemental oxygen Oral Aspirin Sublingual nitroglycerin 0.4 mg every 5 minutes x 3 as needed for chest pain Continuous pulse-oximetry Intravenous access Continuous cardiac monitoring Continuous BP monitoring EKG, 12 Lead, stat The history and physical examination complemented by selected tests such as chest X-ray, EKG, cardiac enzymes allow the physician to accurately diagnose most causes of chest pain, especially CAD. Therefore, we will also do the following Physical Exam: General appearance HEENT/Neck Heart examination Lung examination Abdomen Rectal exam (As this patient may require Heparin for CAD) Musculoskeletal (for possible DVT) Order: Chest X-ray, PA, portable, stat Cardiac enzymes, CK-MB and troponin-T, stat and every 8 hours x 2, Results: Chest/lungsThe chest wall is normal. The diaphragm and chest move equally
and symmetrically with respiration. No abnormality is detected on
percussion and auscultation.
CVSNormal S1 and S2. No murmurs, rubs, gallop, or extra sounds. Pulses
are normal. There is no jugular venous distension. Blood pressure is
equal in both arms.
EKGNormal sinus rhythm with 3 mm ST depression and T wave inversion in
lead II, III and AVF.
Pulse oximetryShows O2 saturation of 96% on 2-lit nasal cannula & 92% on
room air.
Cardiac enzymes and CXRPending
Cardiac monitorNo change of vitals from the time of admission.
Heme occultNegative Patient is still complaining of pain. His history, CAD risk factors such as smoking, HTN, family history, and the EKG findings of T wave inversion suggest the diagnosis of either unstable angina or non-Q wave infarction. In cases of unstable angina, troponins or CK-MB are not elevated but they are elevated in cases of non-Q wave infarcts. However, even in cases of non-Q wave infarcts, troponins levels may not be detectable at initial presentation. We will start heparin and anti-ischemic therapy in this patient. Order review: Shift to ICU PTT/PT stat IV heparin, continuous with every 6 hours PTT or Enoxaparin Q12 hours without frequent PTT monitoring IV nitroglycerin, continuous (blood pressure should be monitored as hypotension may develop) IV Metoprolol 5mg x 3 (5 minutes apart) Bed rest, complete NPO, as this patient may require emergency catheterization Input and output charts CBC with differential, stat and daily to monitor heparin-induced thrombocytopenia Basic metabolic panel (BMP), stat and daily Results: Cardiac enzymes are within normal limits. Discussion: The guidelines for the management of USA/NSTEMI are: Bed rest with continuous ECG monitoring in patients with ongoing rest pain.
NTG, sublingual, followed by intravenous administration, for the immediate
relief of ischemia.
Aspirin should be given as early as possible. Clopidogrel is used in patients
who are unable to take ASA because of allergic reactions or major
gastrointestinal intolerance.
Pulse oximetry and/or ABG
Supplemental oxygen for patients with cyanosis or respiratory distress
IV Morphine when the chest pain is not immediately relieved with NTG or when
acute pulmonary congestion and/or severe agitation is present.
IV beta-blocker followed by a oral dose provided there are no
contraindications. The goal of the treatment is to bring the heart rate down
to 60-70/min. If there are any contraindications for beta blockers and the
patient is having continuous or frequently recurring, a nondihydropyridine
calcium antagonist (e.g., verapamil or diltiazem) can be used as initial
therapy in the absence of severe LV dysfunction or other contraindications.
Routine use of ACEI to all patients with USA/NSTEMI is a class II
recommendation. However, an ACEI is used when hypertension persists despite
treatment with NTG and a beta-blocker, in patients with LV systolic
dysfunction and in diabetic patients.
Anticoagulation with LMWH or intravenous unfractionated heparin should be
added to antiplatelet therapy with ASA and/or clopidogrel. Enoxaparin is the
best studied of all. Heparin should be given for at least 2 days.
A platelet GP IIb/IIIa antagonist (Tirofiban or eptifibatide) should be
administered, in addition to ASA and heparin, to patients in whom
catheterization and PCI are planned.
Early invasive therapy is indicated for high-risk patients with UA. Patients
with refractory ischemia, recurrent symptoms, ST segment depression, and
hemodynamic instability are at high risks. These patients should be referred
for angiography and revascularization. In the absence of these findings,
either an early conservative or an early invasive strategy in hospitalized
patients without contraindications for revascularization.
Role of statin therapy is conflicting. However, in the acute setting the
mechanism of benefit from statin therapy probably involves anti-inflammatory
effects rather than the lipid lowering. The other added benefit is, studies
have shown that the long term compliance is better if the statins are started
before the discharge.
Thrombolytic therapy is not indicated in the treatment of USA/NSTEMI and
should not be used. Order review: Shift to ward and continue the above treatment. Repeat 12 lead EKG Order fasting lipid panel LFTs (for baseline before you start statins) Trans thoracic echocardiography Cardiac catheterization Obtain TSH if the patient has abnormal lipids especially elevated triglycerides. Order review: Aspirin, continuous Sublingual nitroglycerin, continuous as needed Atenolol, oral, continuous Parvastatin, continuous Patient education Cessation of cigarette smoking Limit alcohol Exercise program Medication compliance Relaxation techniques Low sodium diet Follow up visit at two to six weeks Diagnosis: Unstable angina