Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency...
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Transcript of Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency...
Approach to the ED Patient with Chest Pain
University of Utah Medical Center
Division of Emergency Medicine
Medical Student Orientation
The Stats
•5.4% of all ED visits–High volume–High risk
•$$$ malpractice claims –Misdiagnosis
–Delay in treatment
•< 1/3 have myocardial ischemia or infarction
Common Etiologies of Life-threatening Chest Pain
1. Acute MI
2. Unstable angina
3. Aortic Dissection
4. Pulmonary Embolism
5. Spontaneous Pneumothorax
6. Esophageal Rupture (Boerhaave’s Syndrome)
Acute MI
Acute MI
• PMHx– Med Hx
• HTN• DM• Cholesterol
– Meds– FHx
• Immediate relatives CAD
– Social Hx• Tobacco• Drugs• Exercise• Stressors
• HPI– Onset– Palliates/Provokes– Quality– Radiation– Severity– Time course– Undo (what have they
done to “undo” their pain)
• Typical Symptoms– Crescendo pain
• Crushing• Pressure• Tightness
– Radiation• Arms• Jaw• Neck
– Associated Symptoms• Nausea• Vomiting• Diaphoresis• Shortness of breath
• Risk Factors– HTN– Diabetes– High cholesterol– Obesity– Male– Family history– Smoker– Sedentary– Post-menopausal
Acute MI
• But don’t be fooled – Atypical symptoms
• Stridor• Tooth pain• Headache/neck pain
– Atypical demographics• Young• Female
– Cocaine use– Dissection
• Aorta• Coronary arteries
Initial Work-up
• ECG/repeat ECG– before you even step foot in the room!
• CXR• Labs
Enzyme Rise Peak Baseline
Myoglobin 1-2 h 4-6 h 24 h
Troponin 3-6 h 12-24 h 7-10 d
CKMB 4-6 h 12-36 h 3-4 d
LDH 12 h 24-48 h 10-14 d
ECG• STEMI
– 1mm ST elevation in 2 limb leads
– 2mm ST elevation in two contiguous anterior leads
– Reciprocal changes
• Ischemia– ST flattening– ST depression
Treatment
• Anti-platelet– ASA– Plavix
• Heparin• Analgesia
– Nitrates– Narcotics
• B-blockade– No longer recommended in STEMI patients
• Oxygen• Thrombolytics vs. Cath Lab
Missed MI
• ~ 2% missed infarction rate– 25% had missed ST
elevation – 15% had Hx of
nitroglycerin use– 25% died or potentially
lethal outcome!
Unstable Angina
Angina vs. MI
• Heart muscle– death in MI– Ischemia in angina
• Stable vs. Unstable Angina
Presentation of Angina
• Angina– Established character,
timing, duration of CP– Transient,
reproducible, predictable
– Easily relieved by rest or SL NTG
– Reduced coronary flow through fixed atherosclerotic plaques
• Unstable Angina– Angina deviating from
normal pattern– Rest angina > 20 min– New-onset angina,
previously undiagnosed– Increasing angina or
change in class
Evaluation
• Detailed history
• Physical
• ECG/repeat ECG
• CXR
• Labs
Risk Stratify
While this is recommended, exactly how to do it is controversial. There are several scoring systems. They each pros and cons. How risk stratification is will vary from institution to institution.
• TIMI score
• GRACE
• Braunwald Risk Stratification
Risk Stratify
• High/Moderate = admission to r/o MI– ASA– SL NTG for pain x3 then paste if pain free– NTG gtt if pain continues– IV heparin – B-blockade
• Low = provocative testing– From department – Low-risk obs pathway
Aortic Dissection
• 25-50% mortality in 24 hours
Aortic Dissection-Typical Symptoms
• Onset• Palliates/provokes• Quality • Radiation • Severity • Time course • Undo
• sudden, chest/back• nothing!• intense ripping, tearing, cutting• chest to back, flank, extremities• 10/10!• Constant• nothing
Aortic dissection-caveat
• Only about 30% present typically
• This can be a great mimicker
• Neurologic sx’s + CP = think about dissection
Aortic Dissection
• Risk Factors– Trauma (high velocity)– HTN– Men 3:1– Congenital abnormal aortic
valve– Coarctation of aorta– Turner’s Syndrome– Cocaine– Pregnancy– Connective tissue d/o
• Marfan’s• Ehlers-Danlos
– Vascular damage• Card cath, CABG, IABP
Aortic Dissection
• Physical Exam– Aortic regurgitation
(diastolic murmur)– Loss/decreased pulse– Sternoclavicular
heave/pulsation– JVD
• tamponade
Aortic Dissection
• Evaluation– CXR– ECG– TEE– MRI– CT
CXR findings
• Dilated ascending aorta
• Dilated aortic knob
• Apical pleural cap
• Depression of L mainstem bronchus
• Displacement of trachea to R
• Widened mediastinum
Sensitivity of 67%
93% Sensitivity 87% Specificity
98% Sensitivity 97% Specificity
97% Sensitivity 77% Specificity
LVH, Infarct, Ischemia
Aortic Dissection
• Initial Management– Control HTN and shear forces = IV infusions
• B-blocker + Nitroprusside• Labetalol
• Cardiothoracic Surgery Consult– For dissections involving the aortic root
Type 1: ascending & descending; Type 2: ascending only; Type 3: Descending only; Type A: Ascending aorta; Type B: Descending aorta
Aortic Dissection
• Suggested reading (IRAD):– “The International Registry of Acute Aortic
Dissection: New Insights Into an Old Disease” JAMA Feb 16, 2000 Vol 283 No 7.
Pulmonary Embolism
To be discussed in another lecture
Spontaneous Pneumothorax
Spontaneous Pneumothorax
• Absence of trauma• Primary = no lung
disease• Secondary =
underlying lung disease
Pneumothorax
• Presentation may vary– Sudden onset
• Sharp, pleuritic pain, radiates to shoulder
– Gradual symptoms• Progressive dyspnea over weeks…
Spontaneous Pneumothorax
• Risk Factors– Smoker:Non-smoker 120:1– COPD/asthma– Malignancy– Infectious
• Abscess
• TB
• PCP
– Pulmonary infarction
– Pneumonoconiosis• Silicosis
• Berylliosis
– Congenital disease• Cystic fibrosis
• Marfan’s
– Diffuse lung disease• Idiopathic Pulm fibrosis
• Eosinophilia granuloma
• Scleroderma
• Rheumatoid
• Sarcoid
• Etc.
Spontaneous Pneumothorax
• Physical exam– Absence or decreased
breath sounds– Tension
pneumothorax• Cyanosis• Tachypnea• Tachycardia• Hypotension• JVD
Spontaneous Pneumothorax
• Imaging– CXR
• Visceral pleural line• +/- Expiratory film
– CT Scan• Help w/size• Cause
Pneumothorax
• Treatment– oxygen– <15% = observation– >15% = chest tube vs. aspiration
Recurrence is common ~ up to 50% in 2-3 yrs.
Esophageal Rupture
Esophageal RuptureBoerhaave’s Syndrome
• Complete tear• Esophageal contents
leak into mediastinum• Mediastinitis• SICK!
Esophageal Rupture
• Presentation– Chest and neck pain– Often recent instrumentation of esophagus– Hx of forceful vomiting
Esophageal Rupture
• Evaluation & Diagnosis– Subcutaneous emphysema– Hammon’s Sound– Pleural effusion
– CXR– CT– Esophagram
Esophageal Rupture
• Management– Surgical!– 80-90% survival if fixed within 24 hours
Chest Pain Summary
• High index of suspicion
• Broad differential
• Risk stratification
• Evidence-based medicine
• Do what is right for your patient