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.
2.
3.
4.
5.
6.
Acute MI
Unstable angina
Aortic Dissection
Pulmonary Embolism
Spontaneous Pneumothorax
Esophageal Rupture (Boerhaave’s
Syndrome)
Acute MI
Acute MI
• • HPI
Typical Symptoms
––Onset
Crescendo pain
• Crushing
– Palliates/Provokes
• Pressure
– Quality
• Tightness
––Radiation
Radiation
• Arms
– Severity
• Jaw
– Time
course
• Neck
––Undo
(whatSymptoms
have they
Associated
done
to “undo” their
• Nausea
pain)
• Vomiting
• Diaphoresis
• Shortness of breath
• • PMHx
Risk Factors
– –Med
HTNHx
• HTN
– Diabetes
• DM
– High cholesterol
• Cholesterol
– Obesity
– Meds
– Male
– FHx
– Family history
• Immediate relatives CAD
Smoker
– –Social
Hx
– Sedentary
• Tobacco
– Post-menopausal
• Drugs
• Exercise
• Stressors
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
• STEMI
ECG
– 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
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 Rupture
Boerhaave’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