Approach to the ED Patient with Chest Pain

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 • Acute MI • Unstable angina • Aortic Dissection • Pulmonary Embolism • Spontaneous Pneumothorax • Esophageal Rupture (Boerhaave’s 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) Acute MI • 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 don’t 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

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

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. 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 Presentation of Angina

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. Aortic Dissection • 25-50% mortality in 24 hours

19. 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-Typical Symptoms

20. Aortic dissection-caveat • Only about 30% present typically • This can be a great mimicker • Neurologic sx’s + CP = think about dissection

21. 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

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. Spontaneous Pneumothorax • 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. 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

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