Chest Pain in the ED

							Jorge L. Falcon-Chevere, MD, FAAEM, FACEP
Program Director
UPR Emergency Medicine Residency Program
Introduction
•   5 – 7% of total ED visits / year.
•   3 million hospitalizations / year.
•   70 % don’t have ACE.
•   $3 billions annual cost.
•   0.4 – 4 % sent to home with an AMI.
•   EP has a pivotal role.
•   EP must R/O & treat life threatening conditions.
Pathophysiology
• Difficult to diagnose.
• Group of symptoms often can’t identify organ system
    involved.
•   MS, CV, pulmonary & GI system share afferent pathways.
•   All results in similar complaints.
•   Vagueness of symptoms due to visceral innervations.
•   Age, gender & comorbid disease (Diabetes) alters the pts’
    perception.
Prehospital Care
 • EMS can obtain & transmit ECG & focused history via
   cell phone or fax.
 •    time for fibrinolytic administration,   the number of
   patients treated &     reduce mortality from AMI.
 • Physicians can prepare the ED for workup &
   reperfusion.
 • Goal:
      - Door to needle time: < 30 min.
      - Door to balloon time: 60 - 90 min.
Triage triage by nurse: 40 % of AMI send to low acuity
• Traditional
     areas.
 •   Rapid identification of patients with suspected ACS.
 •   Immediate transport to an acute care area.
 •   Standing orders: ivf, oxygen, pulse oxymeter, ECG, and C
     – Xray.
 •   ECG: done & evaluated by physician in less than 10 min.
 •   Chest pain protocol (Graff et al): sensitivity of AMI from
      67 to 93 %.
             - Candidate > 30 y/o with chest pain.
             - Candidate > 50 y/o with palpitation, weakness,
     syncope, SOB.
Initial Clinical Exam
• Limitations: sensitivity of initial ECG goes from 20
 – 60 %, CK-MB < 4 hrs is poor to detect AMI.

• Cornerstone:
     - initial history, PE, ECG.
     - Best information to risk-stratify patients.
Medical History
 • Should target life threatening conditions:
       - ACS, PE.
       - Aaortic dissection, Pneumothorax or Esophageal rupture.

 • Questions:
       - Age & gender.
       - Family cardiac history.
       - Prior AMI / ACS (Risk     5 times).
       - Stress test, cardiac catheterizations, CABG, stenting.
       - Pain: - *** PQRST***
                - Same pain as previous AMI / ACS (additional relative
  risk 2.8).
                - Pain radiation to jaw, left arm, right shoulder, both
  arms VS pleuritic, sharp / stabbing, positional, reproduced with
  palpation.
History
   - Aortic dissection: sudden onset, sharp, severe,
tearing, anterior chest (60%), radiating (28%), migratory
(16%), neuro deficits + chest pain (occlusion of cerebral /
spinal artery).

   - Pulmonary Embolism: peripheral pain, pleuritic, not
reproducible with palpation, radiation is unusual,
substernal chest pain (only 4 %), hemoptysis.

   - Boerhaave’s: vomiting & pain on swallowing.

  - Pericarditis: pain refers to neck & acromial region,
worsens with inspiration & swallowing, lying supine and
improves leaning forward.
History
 - Associated symptoms: SOB, weakness,
diaphoresis, dizziness, syncope, abdominal pain.

 - Old ECG changes: LBBB.

 - Comorbid diseases: HBP, CHF, DM, CAD.
History
• Risk factors:
     - DM, HTN, smoking, hypercholesterolemia, family
 history, ETOH or Cocaine abuse.
     - “The absence of risk factors does not exclude ACI
 as an etiology for the patient’s pain.”

• Medications: anti-anginal, anti-arrhythmic, anti-
  hypertensive, digoxin.
    Vital Signs
• Always Check V/S

• Hypotension + Chest pain: risk      3 times to have AMI.
• Fever: pneumonia, mediastinitis, myocarditis.

• Tachypnea: most common sign of PE.

• Tachycardia: early pericarditis, myocarditis, PE.

• Bradycardia: conduction defect due to right coronary
  artery occlusion.

• Pulse oxymeter: PE.
Head & Neck Exam
• Kussmaul’s sign:
    - paradoxical    in jugular venous distention with
 inspiration.
    - Pericardial tamponade, RHF, TPNT, PE, AMI.

• S/Q Emphysema: PNT or pneumomediastinum.
• Carotid / aortic bruits: CAD.
Heart & Lungs Examination
• Sign of respiratory distress:
     - Nasal flaring, intercostal retractions, use of
 accessory muscles.
     - PNT or massive pleural effusion: unilateral
 absence of breath sounds.
     - Wheezing & rales: asthma, foreign body,
 BKP, CHF or PE.
     - Rales: left heart failure.
Chest Wall Examination
• Even in presence of chest wall tenderness, Always
  consider life-threatening causes of chest pain.

• Costochondritis:
     - Inflammation of costal cartilages.
     - Sharp pain, intermittent, dull or pleuritic.

• Tietze’s syndrome: swelling of upper costal cartilage,
  & limited to only one rib.
Chest Wall Examination
• Cervico-precordial angina:
     - dull chest pain mimicking angina due to
 compression of cervical / thoracic ventral nerve roots.
     - Worsens with neck movement, coughing, sneezing
     - Spurling’s maneuver: axial loading of vertebra by
 applying moderate pressure to the top of the head.
     - Always check thoracic skin: Herpes zoster.
Extremities & Pulses Exam
• Extremities:
     - Edema: biventricular or right sided failure.
     - Thrombosis: Unilateral edema with palpable cord.

• Pulse: pulses for symmetry & quality.
    - Check
     - Pulse deficit most common on type II aortic
 dissection.

• Blood Pressure:
     - Check for symmetry cephalad / caudally &
 bilateral.
     - If differential of BP > 20 mmHg between both
 arms, suspect aortic dissection.
Neurologic Exam
• Altered mental status: hemodynamic instability &
 hypoperfusion.

• Proximal aortic dissection: occlusion of carotid or
 vertebral arteries.

• Distal aortic dissection: produce spinal cord
 ischemia or ischemic peripheral neuropathies.
Acute Coronary Syndromes
• Stable Angina Pectoris.

• Unstable Angina Pectoris.

• Acute Myocardial Infarction:
   - ST elevation MI.
   - Non ST Elevation MI.
  I lateral          aVR         V1 septal    V4 anterior


II inferior    aVL    lateral   V2 septal     V5 lateral


III inferior   aVF inferior     V3 anterior   V6 lateral
Acute Pulmonary Embolism
• Insidious & deadly.

• I / 1000 per year.

• Average EP working 15 shifts / month: 2 – 4 cases / year.

• Mortality if untreated: 30 %.

• Mortality if timely diagnosis & treatment: 8 %.

• Risk factors: age, immobilization, recent surgery / trauma,
  active malignancy, previous TE disease.
Acute Pulmonary Embolism
• Diagnosis is difficult.

• Nonspecific symptoms: dyspnea, fatigue, severe pleuritic
  chest pain, syncope.

• Embolic pulmonary infarction: pleuritic pain, dyspnea &
  hemoptysis, is more common in hospitalized.

• ED patients often present with painless dyspnea.

• PE rarely diagnostic.
 Diagnosis
• Cardiac monitor bed, NIBPD, Pulse Oxymeter.

• Supplemental oxygen to keep saturation > 95%.

• IVF: crystalloids initially if hypotension.

• EKG: - S1Q3T3 (12%).
          - Most common finding: non-specific ST-T changes.
          - Completely benign EKG: < 10%.

• ABG: - PaO2 < 81 mmHg (80 %)
          - A-a gradient: - increased gradient (85%)
                          - more sensitive.
Diagnosis
• Portable chest x-ray:
    - may be normal.
    - Elevated dome of one hemidiaphragm (50%).
    - Hamptom's hump / Westermark's sign.


• Venography: - helpful
                - 90% of patients will have DVT.


• V/Q scan: completely normal study R/O PE.
• Spiral CT.
Aortic Dissection
• Males.

• 50-70 years.

• Risk factors: HBP (Most common), connective tissue
  disorders, pregnancy 3rd trimester, CHD, Turner’s
  syndrome, trauma, cocaine abuse.

• Pathophysiology: intimal tear with blood leak & cleave
  from adventicia.

• Propagation depends upon BP & dP/dT.
Aortic Dissection
• Mortality rate: if untreated
     - 33%: 24 hrs.
     - 50%: 48 hrs.
     - >75%: 2 weeks.
     - 90%: 1-3 month.
       Classifications:

• Debakey:
      - Type I: ascending aorta & part of distal
    aorta. (Most common).
      - Type II: ascending aorta only.
      - Type III: descending aorta only.
         * Subtype IIIA (diaphragm).
         * Subtype IIIB (Beyond diaphragm).
•    Stanford:
       - Type A: ascending aorta (I,II).
       - Type B: descending aorta (I).
Radiologic findings of Aortic Dissection

 • Mediastinal widening: > 8 cm.
 • Change in thoracic aorta when compared to previous x-rays.
 • Eggshell sign: pathognomonic.
 • Blurred aortic knob.
 • Double density appearance (false channel is less
   radiopaque).
 • Right side: - Deviation of esophagus.
                  - Shift & elevation of right bronchus.
                  - Deviation of right paraspinus line.
 • Left side:    - pleural cap.
                  - Depressed left mainstem bronchus.
                  - Pleural effusion.
ECG Changes
• Abnormal in most patients.
• Changes consistent with AMI (40%).
• Varying degrees of AV Block (dissection into
  ventricular septum).
• LVH.
Esophageal Rupture
• AKA Boerhaave’s syndrome.
• Rare / potentially lethal disease.
• Most occur during endoscopy, less common after
    vomiting.
•   Toxic appearance.
•   Chest / abdominal pain.
•   Most common sign is diminished breath sounds.
•   S/Q air on root of neck / chest.
•   Combination: PNT, pneumomediastinum and / or pleural
    effusion.
•   Dx: C-Xray, swallowing studies, endoscopy, CT Scan.
Pneumothorax
• Collection of air in the pleural space.
• Classification:
   - Primary spontaneous PNT:
       * male, young, healthy individuals, smokers, s/p vigorous
 exercises.
       * Rupture of a subpleural bleb.
       * Causes: pressure changes, Valsalva maneuver (maihuana,
 cocaine).
       * Marfan’s syndrome.
    - Secondary spontaneous PNT:
       * > 40 years old.
       * COPD, asthma, chronic bronchitis, cystic fibrosis, BKP, TB,
 fungal infection, sarcoidosis, aerosolized pentamidine, smoker &
 catamenial pneumothorax.
    - Iatrogenic PNT: Subclavian vein + CPR (most common cause
 in ED), mechanical ventilator, bronchoscopy.
ED Care & Disposition
• Determine stability of patient.

• If tension pneumothorax:
     - Immediate needle thoracostomy.
     - Never take C-Xray prior to treatment.

• SmallNRM
    -
        spontaneous pneumothorax: < 10%

     - Inpatient observation, C-Xray after 6 hrs.
     - If completely reabsorbed then D/H.
ED Care & Disposition
• TubeCollapse of theif:
     -
       thoracostomy
                       lung.
     - Severe underlying pulmonary disease.
     - Significant dyspnea.
     - Helicopter transport.
•Simple catheter aspiration:
     - uncomplicated spontaneous pneumothorax.
     - C-Xray s/p procedure.
     - If full expansion of the lung on 6 hr post-
 procedure x-ray: D/H.
     - Watch for pulmonary edema due to rapid re-
 expansion of PNT.