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Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation
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Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

Mar 26, 2015

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Page 1: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

Approach to the ED Patient with Chest Pain

University of Utah Medical Center

Division of Emergency Medicine

Medical Student Orientation

Page 2: 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

Page 3: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

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)

Page 4: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

Acute MI

Page 5: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

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

Page 6: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

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

Page 7: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

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

Page 8: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

ECG• STEMI

– 1mm ST elevation in 2 limb leads

– 2mm ST elevation in two contiguous anterior leads

– Reciprocal changes

• Ischemia– ST flattening– ST depression

Page 9: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

Treatment

• Anti-platelet– ASA– Plavix

• Heparin• Analgesia

– Nitrates– Narcotics

• B-blockade– No longer recommended in STEMI patients

• Oxygen• Thrombolytics vs. Cath Lab

Page 10: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

Missed MI

• ~ 2% missed infarction rate– 25% had missed ST

elevation – 15% had Hx of

nitroglycerin use– 25% died or potentially

lethal outcome!

Page 11: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

Unstable Angina

Page 12: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

Angina vs. MI

• Heart muscle– death in MI– Ischemia in angina

• Stable vs. Unstable Angina

Page 13: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

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

Page 14: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

Evaluation

• Detailed history

• Physical

• ECG/repeat ECG

• CXR

• Labs

Page 15: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

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

Page 16: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

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

Page 18: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

Aortic Dissection

• 25-50% mortality in 24 hours

Page 19: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

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

Page 20: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

Aortic dissection-caveat

• Only about 30% present typically

• This can be a great mimicker

• Neurologic sx’s + CP = think about dissection

Page 21: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

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

Page 22: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

Aortic Dissection

• Physical Exam– Aortic regurgitation

(diastolic murmur)– Loss/decreased pulse– Sternoclavicular

heave/pulsation– JVD

• tamponade

Page 23: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

Aortic Dissection

• Evaluation– CXR– ECG– TEE– MRI– CT

Page 24: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

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%

Page 25: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.
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93% Sensitivity 87% Specificity

Page 29: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.
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Page 31: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

98% Sensitivity 97% Specificity

Page 32: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

97% Sensitivity 77% Specificity

Page 33: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

LVH, Infarct, Ischemia

Page 34: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

Aortic Dissection

• Initial Management– Control HTN and shear forces = IV infusions

• B-blocker + Nitroprusside• Labetalol

• Cardiothoracic Surgery Consult– For dissections involving the aortic root

Page 35: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

Type 1: ascending & descending; Type 2: ascending only; Type 3: Descending only; Type A: Ascending aorta; Type B: Descending aorta

Page 36: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

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.

Page 37: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

Pulmonary Embolism

To be discussed in another lecture

Page 38: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

Spontaneous Pneumothorax

Page 39: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

Spontaneous Pneumothorax

• Absence of trauma• Primary = no lung

disease• Secondary =

underlying lung disease

Page 40: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

Pneumothorax

• Presentation may vary– Sudden onset

• Sharp, pleuritic pain, radiates to shoulder

– Gradual symptoms• Progressive dyspnea over weeks…

Page 41: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

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.

Page 42: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

Spontaneous Pneumothorax

• Physical exam– Absence or decreased

breath sounds– Tension

pneumothorax• Cyanosis• Tachypnea• Tachycardia• Hypotension• JVD

Page 43: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

Spontaneous Pneumothorax

• Imaging– CXR

• Visceral pleural line• +/- Expiratory film

– CT Scan• Help w/size• Cause

Page 44: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.
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Page 48: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.
Page 49: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

Pneumothorax

• Treatment– oxygen– <15% = observation– >15% = chest tube vs. aspiration

Recurrence is common ~ up to 50% in 2-3 yrs.

Page 50: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

Esophageal Rupture

Page 51: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

Esophageal RuptureBoerhaave’s Syndrome

• Complete tear• Esophageal contents

leak into mediastinum• Mediastinitis• SICK!

Page 52: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

Esophageal Rupture

• Presentation– Chest and neck pain– Often recent instrumentation of esophagus– Hx of forceful vomiting

Page 53: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

Esophageal Rupture

• Evaluation & Diagnosis– Subcutaneous emphysema– Hammon’s Sound– Pleural effusion

– CXR– CT– Esophagram

Page 54: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.
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Page 56: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.
Page 57: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

Esophageal Rupture

• Management– Surgical!– 80-90% survival if fixed within 24 hours

Page 58: Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

Chest Pain Summary

• High index of suspicion

• Broad differential

• Risk stratification

• Evidence-based medicine

• Do what is right for your patient