”� علمًا فيه يلتمس � طريقًا سلك من.“ الجنة إلى � طريقًا به له الله سهل

Mohsen M. ElshafeyPulmonary / Critical Care MD

Mansoura university

Mohsen M. ElshafeyPulmonary / Critical Care MD

Mansoura university

ObjectivesObjectivesCauses Causes

Problem orientationProblem orientation

DiagnosisDiagnosis

How can you treat?How can you treat?

Heart Heart lunglung

GITGIT

Panic Panic Drugs Drugs

Cage Cage

Heart Heart lunglung

GITGIT

Panic Panic Drugs Drugs

Cage Cage

Cardiac causes of chest Cardiac causes of chest painpain

AAngina.ngina.AAcute Myocardial Infarction.cute Myocardial Infarction.AAortic dissection/ Stenosis.ortic dissection/ Stenosis.

AArrythmia.rrythmia.

PPericarditisericarditis..

Heart Heart lunglung

GITGIT

Panic Panic Drugs Drugs

Cage Cage

Lung causes of chest painLung causes of chest pain

PPulmonary embolisimulmonary embolisim..PPneumothoraxneumothorax..PPneumonianeumonia..

PPleursy / leursy / AAcute mediastinitiscute mediastinitis..

PPancost tumourancost tumour

Heart Heart lunglung

GITGIT

Panic Panic Drugs Drugs

Cage Cage

Gastrointestinal causes of Gastrointestinal causes of chest painchest pain

GGERD.ERD.

AAcute cholecystitis.cute cholecystitis.

AAcute pancreatitiscute pancreatitis

OOesophageal dysmotilityesophageal dysmotility

Heart Heart lunglung

GITGIT

Panic Panic Drugs Drugs

Cage Cage

Thoracic cage causes of Thoracic cage causes of chest painchest pain

TTitez Syndromeitez Syndrome..

RRadicular Syndromeadicular Syndrome..

RRib fractureib fracture..

MMyalgiayalgia..

Heart Heart lunglung

GITGIT

Panic Panic Drugs Drugs

Cage Cage

Psychatric causes of chest Psychatric causes of chest painpain

IIrritable heart syndromerritable heart syndrome..

PPanic disorderanic disorder..

HHyperventilation syndromeyperventilation syndrome..

NNeurocirculatory astheniaeurocirculatory asthenia..

Heart Heart lunglung

GITGIT

Drugs Drugs

Cage Cage

Panic Panic

Druges causesing chest Druges causesing chest painpain

CocaineCocaine ..Cardiac ischemiaCardiac ischemia

pneumothoraxpneumothorax

NBNB Beta blocker is contraindicated Beta blocker is contraindicated

Pain thershold / Culture bachground.Pain thershold / Culture bachground.

Risk factoresRisk factores

Symptomatic / Aetiological treatment.Symptomatic / Aetiological treatment.

Pain and analgesicsPain and analgesics

Where to treat?Where to treat?

SoSoOver DXOver DX Under DXUnder DX

ECG

X Ray

Enzymes

Echo

Anterior M I

Posterior M I

Pulmonary Embolisim

X Ray

CT- Chest

ABG

Echo

Blood Markers

Severity of presentationSeverity of presentation

Acute massive PE. Acute massive PE.

PE without infarction. PE without infarction.

Pulmonary infarction. Pulmonary infarction.

Only < 50% have clinical Only < 50% have clinical

manifestations) manifestations)

Absence of documented DVT Absence of documented DVT

doesn’t exclude PE. doesn’t exclude PE.

Upper extremities DVT should Upper extremities DVT should

be considered in ICU. be considered in ICU.

RememberRemember

Severe hypoxemia associated with Severe hypoxemia associated with

disappearance of Rt vent failure disappearance of Rt vent failure

manifestation indicates Rt – left shunt manifestation indicates Rt – left shunt

paradoxical embolism that carry very paradoxical embolism that carry very

bad prognosis.bad prognosis.

Prevent Prevent reembolizationreembolization

Promote Promote LysisLysis

Prevent Prevent ComplicationsComplications

Aim of TreatmentAim of Treatment

1.1. Heparin. Heparin.

- - Dose.Dose. - Monitoring.- Monitoring.

- No SC route- No SC route..

2.2. LMWH. LMWH.

3.3. Thrombectomy.Thrombectomy.

4.4. Thrombolytic therapy.Thrombolytic therapy.

5.5. Supportive treatment.Supportive treatment.

Thrombolytic therapy.Thrombolytic therapy.

Indication:Indication:

Massive pulmonary embolism > 50%. Massive pulmonary embolism > 50%.

Young patient with 30%. Young patient with 30%.

Haemodynamical unstable patient. Haemodynamical unstable patient.

Echo findings (previously mentioned). Echo findings (previously mentioned).

Timing: Timing:

Within 24h of onset of symptoms. Within 24h of onset of symptoms.

May extend up to 2 weeks but early May extend up to 2 weeks but early interference is better. interference is better.

Thrombolytic therapy.Thrombolytic therapy.

Dose:Dose:

Bolus, 250.000 within 30 minutes. Bolus, 250.000 within 30 minutes.

Maintenance, 100.000 / h for 24h Maintenance, 100.000 / h for 24h extending to 48h-72h in PE + DVTextending to 48h-72h in PE + DVT. .

Monitoring Monitoring

Thrombin timeThrombin time. .

Thrombolytic therapy:Thrombolytic therapy:

ContraindicationsContraindications

a) Absolute:a) Absolute:

Intracranial - spinal diseases. Intracranial - spinal diseases.

Traumatized patient. Traumatized patient.

Recent surgery (4 weeks). Recent surgery (4 weeks).

b) Relative: b) Relative:

Uncontrolled HTN ≥ 200/120. Uncontrolled HTN ≥ 200/120.

Thrombocytopenia. Thrombocytopenia.

Active peptic ulcer. Active peptic ulcer.

Hx of S.K in previous 6 months. Hx of S.K in previous 6 months.

Complications: Complications: Sever hemorrhage. Sever hemorrhage.

Anaplylactic shock. Anaplylactic shock.

Fever. Fever.

Hypotension. Hypotension.

Value of thrombolytic therapy:Value of thrombolytic therapy: 80% lysis within 180 minutes. 80% lysis within 180 minutes.

Preserve pulmonary microcirculation. Preserve pulmonary microcirculation.

Decrease incidence of post PE increased Decrease incidence of post PE increased pulmonary vascular resistance. pulmonary vascular resistance.

Indication of MV in PE Indication of MV in PE

Non responsive tachycardia – Non responsive tachycardia –

tachypnea. tachypnea.

Refractory severe hypoxemia. Refractory severe hypoxemia.

Unrecoverable shock. Unrecoverable shock.

PE complicated by ARDS. PE complicated by ARDS.

Pneumothorax

http://www.primary-surgery.org/ps/vol2/html/images/img-0324.png

Acute mediastinitis

Pneumonia

ارْض بما قسم الله لك تكن أغنى الناس

GERD

Medication package Medication package

Nitroglycerin/ Beta blockers/ OygenNitroglycerin/ Beta blockers/ Oygen

Anticoagulant/ ThrombolyticsAnticoagulant/ Thrombolytics

Sedatives / tranqulizers. Sedatives / tranqulizers.

Proton pump inhibitores/ prokinetics Proton pump inhibitores/ prokinetics

Non steriodal anti-inflammatory. Non steriodal anti-inflammatory.

Anti-viralAnti-viral

Conclusive remarks1-Pain in patient with confusion, hypotension and

dysrrythmia Don’t forget to hosptalize

2-Try to diagnose befor just analgise your patient

3-Chest XRay ECG are basic tools for diagnosis3-

4-Don’t miss patients with AMI otherwise plame your

Self to much5 -Consider presense of risk factors and comorbidity

اسيرا تبقى جاهال تكن وال اميرا تكن استطعت ما تعلم

كلهم الجهال ترى علم حرف يوم كل .....تعلم

الله الله جزاكـــم جزاكـــمخيــــــــراخيــــــــرا