Presentation on theme: "Approach to the ED Patient with Chest Pain"— Presentation transcript:
1Approach to the ED Patient with Chest Pain University of Utah Medical CenterDivision of Emergency MedicineMedical Student Orientation
2The Stats 5.4% of all ED visits High volumeHigh risk$$$ malpractice claimsMisdiagnosisDelay in treatment< 1/3 have myocardial ischemia or infarctionChest pain accounts for over 5% of all ED visits. It is a high volume and high risk presentation, resulting in 20% of malpractice claims in dollars. These are often the result of misdiagnosis (missed MI) and a delay in treatment. Of all the patients who present to the ED with chest pain, less than 1/3 of them actually have myocardial ischemia or infarct. However, there is a broader differential for chest pain which holds significant morbidity and mortality.
3Common Etiologies of Life-threatening Chest Pain Acute MIUnstable anginaAortic DissectionPulmonary EmbolismSpontaneous PneumothoraxEsophageal Rupture (Boerhaave’s Syndrome)Ask students to list the differential diagnosis for life threatening causes of chest pain.
5Acute MI HPI Onset Palliates/Provokes Quality Radiation Severity Time courseUndo (what have they done to “undo” their pain)PMHxMed HxHTNDMCholesterolMedsFHxImmediate relatives CADSocial HxTobaccoDrugsExerciseStressorsTypical SymptomsCrescendo painCrushingPressureTightnessRadiationArmsJawNeckAssociated SymptomsNauseaVomitingDiaphoresisShortness of breathRisk FactorsHTNDiabetesHigh cholesterolObesityMaleFamily historySmokerSedentaryPost-menopausalWe will talk about the “typical’ signs and symptoms – but remember there are many patients who fall outside of this realm. You must keep your differential open and broad.(The McDonald’s man is something that showed up on google.com)
6Acute MI But don’t be fooled Atypical symptoms Atypical demographics StridorTooth painHeadache/neck painAtypical demographicsYoungFemaleCocaine useDissectionAortaCoronary arteriesAgain, many folks can present with atypical symptoms – especially those that are young and female.Cocaine use puts you at risk for early atherosclerosisNot only can the aorta dissect back into the coronary arteries, causing MI, but the coronary arteries themselves can spontaneously dissect, leading to MI.
7Initial Work-up ECG/repeat ECG CXR Labs before you even step foot in the room!CXRLabsGet an ECG before you step foot in the room! Remember, this is only a 12 second snapshot of something that is very dynamic. It is important to repeat the ECG during the patients stay, when their symptoms change (i.e. chest pain resolves, pain returns).CXR is important to help you rule out other etiologies of chest pain, i.e. PTX, PNA, aortic dissection etc.We now use CKMB (absolute value) and troponin for our labs. Remember, the troponin does not approach 100% sensitivity until 12 hours out from the onset of pain. Enzymes indicated myocardial damage. Could your patient be having unstable angina and not necessarily an MI? Thus, enzymes must be used in the context of the patient presentation. Just because the enzymes are negative, does not mean that the patient is safe for discharge home.EnzymeRisePeakBaselineMyoglobin1-2 h4-6 h24 hTroponin3-6 h12-24 h7-10 dCKMB12-36 h3-4 dLDH12 h24-48 h10-14 d
8ECG STEMI Ischemia 1mm ST elevation in 2 limb leads 2mm ST elevation in two contiguous anterior leadsReciprocal changesIschemiaST flatteningST depression
9Treatment Anti-platelet Heparin Analgesia B-blockade Oxygen ASAPlavixHeparinAnalgesiaNitratesNarcoticsB-blockadeNo longer recommended in STEMI patientsOxygenThrombolytics vs. Cath LabAccording to the new guidelines, B-blockers are not longer recommended in acute STEMI!Lytics vs. cath lab depends on the type of facility you are working in. Here, patients will go to the cath lab. If all are busy, lytics will be administered. If you are working in a “sending” hospital, it depends upon the time it will take you to transport the patient to a tertiary care facility with cath ability.
10Missed MI ~ 2% missed infarction rate 25% had missed ST elevation 15% had Hx of nitroglycerin use25% died or potentially lethal outcome!As conservative as we are, we still miss up to 2% of MIs. We discharge them from our EDs.Of these 2%, a quarter of them had missed ST elevation on their ECG. And 25% had a bad outcome!
12Angina vs. MI Heart muscle Stable vs. Unstable Angina death in MI Ischemia in anginaStable vs. Unstable Angina
13Presentation of Angina Established character, timing, duration of CPTransient, reproducible, predictableEasily relieved by rest or SL NTGReduced coronary flow through fixed atherosclerotic plaquesUnstable AnginaAngina deviating from normal patternRest angina > 20 minNew-onset angina, previously undiagnosedIncreasing angina or change in classDiscuss difference between stable and unstable angina
14Evaluation Detailed history Physical ECG/repeat ECG CXR Labs BP in both arms helps with aortic dissection in the differential; similar w/u to MI as you don’t know if the angina is progressing to MI.
15Risk StratifyWhile 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 scoreGRACEBraunwald Risk Stratification
16Risk Stratify High/Moderate = admission to r/o MI ASASL NTG for pain x3 then paste if pain freeNTG gtt if pain continuesIV heparinB-blockadeLow = provocative testingFrom departmentLow-risk obs pathwayWith patients with Angina, we must risk stratify them. First of all, do we think this is cardiac chest pain? Is it MI/angina? If patients are deemed high to moderate risk, they get the full work up and admission; if they are low risk (where we really do not think this is cardiac chest pain, but cannot be sure), we have 2 options here at UMC – admit to ECU as low risk observation pathway (<24 admit for serial cardiac enzymes followed by provocative testing) or provocative testing right from our department (during daylight hours)
18Aortic Dissection 25-50% mortality in 24 hours Morbidity and mortality can be quite high in these patients – we must keep this in our differential for chest pain!
19Aortic Dissection-Typical Symptoms OnsetPalliates/provokesQualityRadiationSeverityTime courseUndosudden, chest/backnothing!intense ripping, tearing, cuttingchest to back, flank, extremities10/10!ConstantnothingThese are the “typical” symptoms. Though I have seen patients present with chest pain relieved by nitrates without radiation to their back, not a severe pain etc. have a dissection. Often it is SUDDEN in onset, this should raise a red flag!
20Aortic dissection-caveat Only about 30% present typicallyThis can be a great mimickerNeurologic sx’s + CP = think about dissection
21Aortic Dissection Risk Factors Trauma (high velocity) HTN Men 3:1 Congenital abnormal aortic valveCoarctation of aortaTurner’s SyndromeCocainePregnancyConnective tissue d/oMarfan’sEhlers-DanlosVascular damageCard cath, CABG, IABPThere are many risk factors for dissection and you should think of all of these as you evaluate your patient.
22Aortic Dissection Physical Exam Aortic regurgitation (diastolic murmur)Loss/decreased pulseSternoclavicular heave/pulsationJVDtamponadeOn physical exam, you may notice a new diastolic murmur or aortic regurgitation if the dissection involves the root – these patients may present hypotensive and in frank shock. Evaluate BP in both arms, evaluate peripheral pulses, if JVD, think about an aortic root dissection that has dissected into the pericardium, causing tamponade.
23Aortic Dissection Evaluation CXR ECG TEE MRI CT Select an image by clicking on the blue button. Continue with slides until you see a blue house button in the lower right hand corner. Click the house and it will return you to this home slide. When you have gone through the imaging, click the button in the lower right hand corner to move you onto the subject, management of aortic dissection.
24CXR findings Dilated ascending aorta Dilated aortic knob Apical pleural capDepression of L mainstem bronchusDisplacement of trachea to RWidened mediastinumVarious findings you are looking for on a CXR to evaluate for aortic dissection); 12-20% of those with aortic dissection will have a normal CXRSensitivity of 67%
33Aortic dissections can dissect into the coronary arteries, causing infarction LVH, Infarct, Ischemia
34Aortic Dissection Initial Management Cardiothoracic Surgery Consult Control HTN and shear forces = IV infusionsB-blocker + NitroprussideLabetalolCardiothoracic Surgery ConsultFor dissections involving the aortic rootStart beta blocker first and then add alpha blockade to lower pressure; if you lower pressure first, you will get a reflex tachycardia, which will increase the shear forces across the aortic wall.
35Stick to Type A (involving ascending aorta) or Type B (descending aorta only);Who has survived an aortic dissection: Dr. Michael E. DeBakey, who devised the surgery to correct aortic dissection (as well as other cardiovascular and vascular techniques). Dr. DeBakey was also noteworthy for being the oldest patient ever to receive his own operation: he was 97 at the time of his surgery on February 9 and 10 of He survived and, though he worked with physical therapists to walk on his own again after suffering muscle deconditioning from prolonged physical inactivity during recovery, retained all of his mental faculties and was back to working nearly a full day until his death of natural causes on July 11, 2008Type 1: ascending & descending; Type 2: ascending only; Type 3: Descending only; Type A: Ascending aorta; Type B: Descending aorta
36Aortic 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.
37To be discussed in another lecture Pulmonary EmbolismTo be discussed in another lectureWill be addressed in the dyspnea lecture.
42Spontaneous Pneumothorax Physical examAbsence or decreased breath soundsTension pneumothoraxCyanosisTachypneaTachycardiaHypotensionJVDWatch out for referred sounds from the good lung. It is best to listen in the axillary region.
45R sided PTX, no pulmonary markings present, at all!
46This patient actually drove himself to the ED from home after having an outpatient CXR for progressive SOB over a month….Actually shows a tension ptx by film with L ptx and shift of mediastinum to the right…but he was stone cold STABLE! Arrow points to collapsed lung parenchyma.