CHEST PAIN CONDITIONS THAT CAN KILL

1. CHEST PAIN CONDITIONS THAT CAN KILL George L. Higgins III, MD, FACEP Professor of Emergency Medicine Maine Medical Center Tufts University School of Medicine

2. All Potentially Deadly… And Painful • Acute Coronary Syndrome • Pneumonia • Pulmonary Embolus • Pneumothorax • Aortic Dissection • Arrow Through the Heart • Lost Love

3. Our Time Together • This course already provides excellent presentations on pneumonia and • acute coronary syndromes • We’ll focus on the other conditions, with special emphasis on the immediate decisions that are required • If you plan to work in the acute care area of medicine, you better be able to sort all of these out!!!

4. Learning Objectives Recognize the acute signs and symptoms in patients with… Pneumothorax Aortic Dissection Pulmonary Embolism Review the emergent management options for these conditions

5. Case 1 This 65 year old man awoke from sleep with sharp left- sided chest pain and shortness of breath He shares that he has COPD He is anxious but more comfortable on supplemental oxygen

6. Case 1 PE: Breathing rapidly on 4L O2 O2Sat 91%, BP 160/90, HR 95 Decreased breath sounds on the left side Most likely unifying diagnosis? Most important? Are you in the Test Zone?

7. Critical Reasoning 101 • Leave the exam room and immediately construct the following list of possible diagnoses: • Most Likely • Most Important • Most Scholarly

8. Higgins Rule 101 • When your • Most Likely and • Most Important • diagnoses match, • STOP Thinking and • START Acting!

9. Most LikelyMost Important PNEUMOTHORAX: Not Likely Tension Are You In The Test Zone?

10. The Test Zone Concept Condition Uncertain? You’re in the Test Zone!! Condition Does Not Exist (don’t test) Condition Does Exist (don’t test) Order Only Valid Tests to Vacate the TZ Δ You only test when you are uncertain Δ You only order valid tests Δ A test is only valid if it can move you out of the TZ Δ The history and physical exam are often the best valid tests

11. Pneumothorax

12. Primary Spontaneous Pneumothorax (PSP) Occurs without precipitating event: e.g. trauma No known lung disease Often younger patients Risk Factors: Smoking Catamenial (thoracic endometriosis) Marfan Syndrome

13. PSP Up to a 50% recurrence rate Most within the 1st year Risk factors of recurrence: Male gender Tall stature Low body weight Continued smoking

14. Secondary Spontaneous Pneumothorax (SSP) Associated with known lung disease COPD Cystic fibrosis Malignancy Necrotizing pneumonia Pneumocystis TB

15. Clinical Presentation Sudden onset of unilateral pleuritic chest pain with dypnea PE: Hypoxia (usual) Decreased chest excursion Diminished breath sounds Hyper-resonant percussion

16. Diagnostic Tests Bedside Ultrasound Immediately available and very accurate Chest X-Ray Usually helpful CT Scan Especially helpful in identifying large COPD-related bullae

17. Bedside Ultrasound Look For Evidence of Lung Sliding

18. CXR Helpful Most of the Time

19. CXR

20. Tension Pneumothorax Diagnose tension pneumothorax based on BOTH the physical exam and the CXR Deep Sulcus Sign + Mediastinal Shift = TP

21. CT Scan:Great for Picking Up “Invisible” Pneumothoraces

22. Beware: Giant Bullae Can Mimic Pneumothorax When in doubt, CT Scan!

23. Treatment Options Supplemental oxygen Can increase air re-absorption rate by 6-fold Observation Catheter aspiration Tube thoracostomy

24. Categorize the Size as Small or Large: Treatment Options are Based on Size At the Apex: <3 cm, Small 3+ cm, Large At the Hilum: <2 cm, Small 2+ cm, Large

25. An Example of a Management Plan

26. Tension Pneumothorax Diagnose tension pneumothorax based on BOTH the physical exam and the CXR Deep Sulcus Sign + Mediastinal Shift = TP

27. True Tension Pneumothorax:A Procedural Emergency We will not be reviewing tube thoracostomy procedures during this limited session, but take time to do so on your own

28. Aortic Dissection

29. Basic Facts An uncommon yet catastrophic condition Due to a tear in the aortic intima Propagation of the dissection can be both distal and proximal Older men most at risk

30. Risk Factors Hypertension Atherosclerosis Vasculitis Collagen disorders Marfan Syndrome Ehlers-Danlos Syndrome Cocaine Weight lifting Iatrogenic

31. Classification Stanford system most commonly used

32. Clinical Presentation Sudden onset of “sharp” or “tearing” chest and/or back pain Type A: more likely chest pain Type B: more likely back or abdominal pain A pulse deficit is relatively common Carotid, Brachial, Femoral

33. Clinical Presentation Complications of ascending aorta dissection Acute aortic valve regurgitation Acute myocardial infarction Thrombolytics + dissection = bad Cardiac tamponade Stroke syndrome Carotid artery involvement

34. Clinical Presentation Complications of descending aorta dissection Mesenteric ischemia Acute renal injury Leg ischemia Spinal cord infraction

35. Diagnostic Tests CXR Readily available Helpful slightly more than half the time Mediastinal widening, pleural effusion, displaced aortic calcification

36. Mediastinal Widening and Loss of the Aortopulmonary Window

37. Mediastinal Widening and Loss of the Aortopulmonary Window

38. Diagnostic Tests CT Readily available Newer scanners impressively accurate MRI Highly accurate but less available Requires stable patient TEE A great bedside option in the unstable patient if available

39. CT

40. CT

41. Emergent Management Type A dissections usually treated surgically Type B dissections usually treated medically

42. Emergent Management Reduce SBP to 100-120 mmHg or lowest level tolerated Start with beta-blocker Decreases shear stress propranolol, metoprolol, labetalol, esmolol Add a vasodilator if additional BP control required nitroprusside, nicardipine, verapamil, diltiazem Always start BB prior to vasodilators

43. Emergent Management If the dissection results in cardiogenic shock from acute aortic valve incompetence, pericardial tamponade, ACS… SCREAM FOR HELP!!! And treat the condition accordingly (not enough time to review all of these conditions during this session)

44. Pulmonary Embolus

45. Classification Massive Causing hemodynamic instability Submassive All other acutely symptomatic PE Untreated symptomatic PE is associated with a nearly 30% mortality rate Usually from recurrent PE

46. PE Risk Factors Since most PE arise from DVT… Immobilization Recent surgery Stroke/paresis/paralysis Malignancy Obesity Hx of prior DVT Always examine the legs when considering the Dx of PE

47. PE Symptoms Acute dyspnea: 70+% Pleuritic chest pain: 40+% Cough: 30+% Wheezing: 20+% Calf/thigh pain/swelling: 40+% Rarely syncope

48. PE Signs Hypoxia is common Tachypnea: 50+% Tachycardia: 20+% Rales: 15+% Decreased breath sounds: 15+% Accentuated P2: 15+% JVD: 15%

49. PE Tests ABG (supportive, not diagnostic) ECG (supportive, not diagnostic) CXR (supportive, not diagnostic) *D-dimer (used to rule out PE) *CT Scan V/Q Scan *Lower Extremity US

50. Classic (But Infrequent) ECG Finding in PE S-I, Q-III, T-III