modul nyeri dada final
TRANSCRIPT
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Approach to the Patient with Chest Pain
Anggreini Susanti
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DEFINISI
Rasa tidak nyaman di toraks anterior yang berlangsung dari bawah mandibula sampai di atas epigastrik
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From Hurst
Differential diagnosis:
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ETIOLOGI
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Nyeri Dada yang Mengancam JiwaNyeri Dada yang Mengancam Jiwa
Sindrom Koroner Akut Emboli Pulmonal Diseksi aorta Ruptur Esofageal Pneumotoraks Perikarditis Cocaine-induced chest pain (akselerasi progresi
aterosklerosis, faktor resiko terjadinya serangan jantung)
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Nyeri Dada yang Tidak Mengancam Nyeri Dada yang Tidak Mengancam JiwaJiwa GERD. Esofagitis. Herpes zoster. Muskuloskeletal Bronkitis (nyeri dada akibat batuk) “Non-Specific Chest Pain”
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Chest Pain
Non Cardiac
Cardiac
PE
PTX
Esophageal disaster
Aortic disease
Myo/pericardium
Coronary disease
Coronary spasm
Obstructive CAD
ACS
Stable angina
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EMBOLI PARU fatal, tingkat kematian 15%. nyeri dada akibat distensi arteri pulmonaris
atau infark di bagian paru yang berhubungan dengan pleura.
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Anamnesis
Emboli masif : mirip infark miokard akut. Emboli kecil: nyeri pleuritik. Sesak nafas Hemoptisis Faktor risiko: DVT, riwayat operasi, imobilisasi
lama, keganasan, hyercoagulability syndromes, usia tua, gagal jantung kongestif, kontrasepsi oral, kehamilan.
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Pemeriksaan Fisik
Hipotensi Takipnea Takikardi Demam yang tidak terlalu tinggi Gejala gagal jantung kanan akut:
peningkatan JVP, S3 gallop, dan bunyi P2 mengeras
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Pemeriksaan Penunjang
Elektrokardiografi: irama sinus atau atrial fibrilasi RAD, p pulmonal, RBBB, S1Q3T3, dan T
wave inversion V1-V4
Laboratorium D dimer, sensitif tidak spesifik AGD: hipoksemia, hipokapnea, dan alkalosis
respiratorik
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Algoritme Diagnosis PE
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Gambaran EKG PE
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Chest Pain
Non Cardiac
Cardiac
PE
PTX
Esophageal disaster
Aortic disease
Myo/pericardium
Coronary disease
Coronary spasm
Obstructive CAD
ACS
Stable angina
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PneumotorakAnamnesa : • Asimptomatik atau datang dengan nyeri dada pleuritik
akut dan sesak napas • Penumotorak primer dewasa muda• Pneumotorak sekunder : a. trauma (KLL – fraktur costae, iatrogenic ,
thorakosentesis)b. Peningkatan tekanan alveolar akibat asma atau
barotrauma (BiPAP, ventilator-associated)c. Ruptur blep pada pasien COPD, TB
d. nekrosis jaringan pada pneumonia, empiema,
kanker
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Pneumotorak
Pemeriksaan Fisik• Suara napas dan VF meningkat pada sisi
pneumotorak• Hipersonor
Penunjang : • Ronsen torak : garis yang memisahkan pleura
viseral dan parietal• Pada pneumotorak yang luas dapat terlihat
mediastinal shift dan kompresi paru kontralateral
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PNEUMONIA
Anamnesis
• Nyeri tajam, seperti ditusuk-tusuk. Pencetus: inspirasi dan batuk.
• Pneumonia tipikal: riwayat batuk berdahak, demam, sesak.
• Pneumonia atipikal: batuk kering, demam ringan, dan gejala ekstrapulmonar (diare, dermatitis, nyeri kepala, nyeri otot)
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• Faktor risiko: usia sangat tua atau sangat muda, gangguan menelan dan proteksi jalan nafas, penyakit paru dasar, gangguan dinding dada, pasien imunokompromis, riwayat dirawat di RS
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Pemeriksaan Fisik
• Tekanan darah normal.
• Takipnea
• Takikardi
• Demam.
• Pemeriksaan paru crackles.
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Pemeriksaan PenunjangLaboratorium:
• darah rutin
• pewarnaan gram dan kultur sputum
• AGD menentukan perlunya support respirasi
Foto thoraks lokasi dan luasnya infilrat
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Chest Pain
Non Cardiac
Cardiac
PE
PTX
Esophageal disaster
Aortic disease
Myo/pericardium
Coronary disease
Coronary spasm
Obstructive CAD
ACS
Stable angina
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Ruptur EsofagusPresentasi Klinis Terjadi di RS: >50% pemakaian instrumen pada
esofagus Traumatik: MVA, trauma dinding dada Spontan: (transmural perforasi)
Muntah (Boerhaave’s Syndrome): vomitus diikuti dengan nyeri dada dan epigastrik yang hebat, takipnea, dyspnea, demam, sianosis, syok
Caustic ingestion, pill esophagitis, Barrett’s, ulkus esophageal pada pasien HIV
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Pemeriksaan Penunjang
Ronsen torak : udara bebas di mediastinal atau peritoneal Dalam beberapa
jam atau hari: mediastinum melebar, efusi pleura
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Pemeriksaan Penunjang: CT scan: Edema
esophagus, extra esophageal air, cairan di periesophageal
Esophagram: Extravasasi dari kontras
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Chest Pain
Non Cardiac
Cardiac
PE
PTX
Esophageal disaster
Aortic disease
Myo/pericardium
Coronary disease
Coronary spasm
Obstructive CAD
ACS
Stable angina
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DISEKSI AORTA
• Laki-laki : perempuan = 2 : 1• Diseksi aorta ascending: usia 50-60
Diseksi aorta descending: usia 60-70
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Anamnesis• Nyeri dada hebat, tajam, mendadak, terus
menerus, semakin bertambah pingsan.
• Nyeri seperti sensasi dirobek.
• Nyeri menjalar ke punggung, rahang, leher, di antara skapula.
• Analgetik narkotik dosis tinggi nyeri tidak hilang
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AnamnesisFaktor risiko:• hipertensi. • congenital heart disease• sindroma Marfan• prosedur pemasangan kateter atau balon intra aorta• kehamilan • merokok • riwayat keluarga • penggunaan stimulan• trauma.
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Pemeriksaan Fisik
• 70% hipertensi
• Hipotensi bila tamponade, ruptur aorta, gagal jantung
• Sugestif : pulsus defisit, regurgitasi aorta, bruit, dan manifestasi neurologis (stroke dan paraplegi)
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Pemeriksaan Penunjang
Foto thoraks:
• kontur aorta abnormal, pelebaran siluet aorta
• trakea deviasi ke arah kanan
• pelebaran mediastinum superior
• calsium sign : pemisahan kalsifikasi aorta dari bagian luar arkus aorta lebih dari 0.5 cm
• efusi pleura bila inflamasi atau hemothoraks akibat ruptur aorta
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Pemeriksaan Penunjang
EKG:
• tidak spesifik
• menunjukkan komplikasi akut iskemik/infark miokard, low voltage QRS kompleks.
• 75%: ST segmen, 25% : LVH.
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Pemeriksaan Penunjang
Biomarker
• sulit mendeteksi adanya diseksi aorta.
• D dimer , tidak spesifik
• D dimer > 1600 ng/ml curiga diseksi aorta.
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Aortic dissection: Classification
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Aortic dissection
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Chest Pain
Non Cardiac
Cardiac
PE
PTX
Esophageal disaster
Aortic disease
Myo/pericardium
Coronary disease
Coronary spasm
Obstructive CAD
ACS
Stable angina
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PERIKARDITIS
ETIOLOGI
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Pemeriksaan Fisik
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Pemeriksaan Penunjang
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Pericarditis: ECG:
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Chest Pain
Non Cardiac
Cardiac
PE
PTX
Esophageal disaster
Aortic disease
Myo/pericardium
Coronary disease
Coronary spasm
Obstructive CAD
ACS
Stable angina
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KARDIAK
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ACS: ECG
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GASTROINTESTINAL
Refluks asam lambung Seperti terbakar, dicetuskan oleh
alkohol, aspirin, kafein, dan makanan. Nyeri berkurang dengan berbaring, lebih
berat di pagi hari saat perut kosong.
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GASTROINTESTINAL
Spasme Esofagus Terasa seperti diremas, mirip dengan angina, Terkadang membaik dengan pemberian
nitrogliserin sub lingual Riwayat sulit menelan, hematemesis, dan
penurunan berat badan.
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GASTROINTESTINALGangguan di bawah diafragma
(ulkus peptikum, pankreatitis, gangguan pada traktus bilier)
Nyeri dada disertai nyeri perut dominan. tidak dicetuskan aktivitas, berhubungan
dengan makanan.
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MUSKULOSKELETAL Nyeri berhubungan dengan batuk, trauma,
cedera, atau peregangan otot. Nyeri singkat, tajam, meningkat dengan
pergerakan dinding dada atau ekstremitas. Kostokondritis, fibromyalgia, osteoartritis,
herpes zoster
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GANGGUAN EMOSIONAL DAN PSIKIATRI Panic disorder : bila didapatkan adanya 3 kali
serangan (takut atau rasa tidak nyaman) diikuti oleh minimal 4 atau lebih gejala nyeri dada, gelisah, rasa tercekik, palpitasi, berkeringat, pusing, mual atau abdominal distress, parestesia, flushing, menggigil, seperti akan mati
34-59% pasien nyeri dada nonkardiak
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Penyebab Umum Nyeri Dada (Sabatine, M.S. Cannon, C. P. 2012)
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