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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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Presentation on theme: "Approach to the ED Patient with Chest Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation."— Presentation transcript:

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

2 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

3 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 (Boerhaaves Syndrome)

4 Acute MI

5 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

6 Acute MI But dont be fooled –Atypical symptoms Stridor Tooth pain Headache/neck pain –Atypical demographics Young Female –Cocaine use –Dissection Aorta Coronary arteries

7 Initial Work-up ECG/repeat ECG –before you even step foot in the room! CXR Labs EnzymeRisePeakBaseline Myoglobin1-2 h4-6 h24 h Troponin3-6 h12-24 h7-10 d CKMB4-6 h12-36 h3-4 d LDH12 h24-48 h10-14 d

8 ECG STEMI –1mm ST elevation in 2 limb leads –2mm ST elevation in two contiguous anterior leads –Reciprocal changes Ischemia –ST flattening –ST depression

9 Treatment Anti-platelet –ASA –Plavix Heparin Analgesia –Nitrates –Narcotics B-blockade –No longer recommended in STEMI patients Oxygen Thrombolytics vs. Cath Lab

10 Missed MI ~ 2% missed infarction rate –25% had missed ST elevation –15% had Hx of nitroglycerin use –25% died or potentially lethal outcome!

11 Unstable Angina

12 Angina vs. MI Heart muscle –death in MI –Ischemia in angina Stable vs. Unstable Angina

13 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

14 Evaluation Detailed history Physical ECG/repeat ECG CXR Labs

15 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

16 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

17 Aortic Dissection

18 25-50% mortality in 24 hours

19 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

20 Aortic dissection-caveat Only about 30% present typically This can be a great mimicker Neurologic sxs + CP = think about dissection

21 Aortic Dissection Risk Factors –Trauma (high velocity) –HTN –Men 3:1 –Congenital abnormal aortic valve –Coarctation of aorta –Turners Syndrome –Cocaine –Pregnancy –Connective tissue d/o Marfans Ehlers-Danlos –Vascular damage Card cath, CABG, IABP

22 Aortic Dissection Physical Exam –Aortic regurgitation (diastolic murmur) –Loss/decreased pulse –Sternoclavicular heave/pulsation –JVD tamponade

23 Aortic Dissection Evaluation –CXR –ECG –TEE –MRI –CT

24 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%




28 93% Sensitivity 87% Specificity



31 98% Sensitivity 97% Specificity

32 97% Sensitivity 77% Specificity

33 LVH, Infarct, Ischemia

34 Aortic Dissection Initial Management –Control HTN and shear forces = IV infusions B-blocker + Nitroprusside Labetalol Cardiothoracic Surgery Consult –For dissections involving the aortic root

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

36 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.

37 Pulmonary Embolism To be discussed in another lecture

38 Spontaneous Pneumothorax

39 Absence of trauma Primary = no lung disease Secondary = underlying lung disease

40 Pneumothorax Presentation may vary –Sudden onset Sharp, pleuritic pain, radiates to shoulder –Gradual symptoms Progressive dyspnea over weeks…

41 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 Marfans –Diffuse lung disease Idiopathic Pulm fibrosis Eosinophilia granuloma Scleroderma Rheumatoid Sarcoid Etc.

42 Spontaneous Pneumothorax Physical exam –Absence or decreased breath sounds –Tension pneumothorax Cyanosis Tachypnea Tachycardia Hypotension JVD

43 Spontaneous Pneumothorax Imaging –CXR Visceral pleural line +/- Expiratory film –CT Scan Help w/size Cause






49 Pneumothorax Treatment –oxygen –<15% = observation –>15% = chest tube vs. aspiration Recurrence is common ~ up to 50% in 2-3 yrs.

50 Esophageal Rupture

51 Esophageal Rupture Boerhaaves Syndrome Complete tear Esophageal contents leak into mediastinum Mediastinitis SICK!

52 Esophageal Rupture Presentation –Chest and neck pain –Often recent instrumentation of esophagus –Hx of forceful vomiting

53 Esophageal Rupture Evaluation & Diagnosis –Subcutaneous emphysema –Hammons Sound –Pleural effusion –CXR –CT –Esophagram




57 Esophageal Rupture Management –Surgical! –80-90% survival if fixed within 24 hours

58 Chest Pain Summary High index of suspicion Broad differential Risk stratification Evidence-based medicine Do what is right for your patient

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