CHEST PAIN

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CHEST PAIN

• Emergency Medicine
• Core Curriculum

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Differential Diagnosis

• Myocardial Infarction
• Angina
• Pericarditis
• Aortic Dissection
• Pulmonary Embolism
• Pneumonia
• Pneumothorax

• GI Etiology
• Muscle Skeletal Etiology

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Core Curriculum Chest Pain
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Case 1

• 40 yo white male presents to the ED with a 30 min
  history of squeezing substernal chest pain
  radiating to left shoulder and jaw associated
  with nausea and diaphoresis. At presentation,
  chest pain intensity is 9/10.

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Core Curriculum Chest Pain
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Myocardial InfarctionHistory/Presentation

• Age gt 35 years
• Sex male gt female
• Duration gt 2 minutes, gt several days
• Location retrosternal, epigastric
• Radiation left jaw, shoulder, arm
• Character pressure, squeezing, burning,
  crushing, tightness, heaviness
• Associated symptoms nausea, vomiting,
  diaphoresis, SOB, light-headed, weakness
• Intensity Scale 1-10

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Core Curriculum Chest Pain
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Vital Signs

• Temp WNL
• HR WNL, tachycardic, bradycardic
• RR WNL, tachypnea
• BP WNL, hypotensive, hypertensive

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Core Curriculum Chest Pain
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Triage

• Medications
• Allergies
• PMHx
• PSHx
• FHx
• Cardiac Risk Factors
• Contraindications to thrombolytic therapy

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Core Curriculum Chest Pain
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Physical Exam

• GEN WDWN W male in mod distress
• HEENT WNL, JVD
• COR NSR, Sinus Tachycardia, Sinus bradycardia,
  SEM, S3, S4,
• CHEST CTA Bilaterally, Basilar rales, rales
  throughout bilateral lung fields
• ABD Non-tender
• BACK without spinal or CVA tenderness
• EXT WNL, PVD, Pedal Edema, symmetric pulses
• RECTAL Hemocult -

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Core Curriculum Chest Pain
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Risk Factors Ischemic HD

• Major (7)
• CAD
• Male
• Hypertension
• DM
• Hypercholestremia
• Family Hx
• Smoking

• Minor (6)
• Obesity
• Hyperuricemia
• Menopause
• Hypothyroidism
• Steroid use
• Type A personality

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Core Curriculum Chest Pain
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EKG

• ST elevation gt 1 mm in two consecutive leads
• ST depression gt 1 mm in two contiguous anterior
  leads (post MI)
• New LBBB

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Core Curriculum Chest Pain
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AMI
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IWMI
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CXR

• WNL
• Cardiomegaly
• Pulmonary Congestion
• Pulmonary Edema

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Core Curriculum Chest Pain
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CXR CHF
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ED Course

• Thrombolytic Therapy
• ASA
• Nitrates
• TPA (Door to Drug time lt 30 minutes)
• Heparin
• Beta - blockers

• Primary Angioplasty
• Cardiology present for transportation to Cardiac
  Catheterization Suite within 30 min

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Core Curriculum Chest Pain
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Thrombolytic Contraindications

• Absolute contraindications
• Internal bleeding, bleeding disorder, persistent
  HTN, Pregnancy, any trauma or surgery in last two
  weeks that could result in bleeding into closed
  space
• CNS neoplasm, aneurysm, AVM, Hx of hemorrhagic
  CVA, AMS
• CVA in last 6 months, intracranial or intraspinal
  surgery in last 2 months, Hx of head trauma in
  last 1 month
• Suspect aortic dissection, Pericarditis
• Previous allergy to streptokinase product (does
  not preclude TPA)

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Core Curriculum Chest Pain
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Thrombolytic contraindications

• Relative contraindications
• Active PUD, CPR gt 10 min, anticoagulated,
  hemorrhagic optho conditions, Hx of uncontrolled
  HTN
• Hx of CVA gt 6 months ago
• Trauma or surgery gt2 weeks ago but lt 2 months ago
• Central line placement

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Core Curriculum Chest Pain
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Disposition

• Thrombolytic therapy
• Coronary Care Unit

• Primary Angioplasty
• Cardiac Catheterization Suite

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Core Curriculum Chest Pain
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Case 2

• 55yo white male with prior history of CAD
  confirmed on angiogram, presents to the ED with
  decreased exercise tolerance, increasing use of
  sublingual nitroglycerin for control of his
  typical anginal pattern (retrosternal chest pain).

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Core Curriculum Chest Pain
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AnginaHistory/Presentation

• Age gt 35 years
• Sex male gt female
• Duration 5 - 20 minutes
• Location retrosternal, epigastric
• Radiation neck, shoulder, arm
• Character pressure, squeezing, burning crushing,
  tightness, heaviness
• Precipitated by exertion
• Relieved with rest and/or nitrates

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Core Curriculum Chest Pain
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Vital Signs

• Temp WNL
• HR WNL, tachycardic, bradycardic
• RR WNL, tachypnea
• BP WNL, hypertensive, hypotensive

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Core Curriculum Chest Pain
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Triage

• Medications
• Allergies
• PMHx
• PSHx
• FHx
• Cardiac risk factors
• Contraindications to thrombolytic therapy

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Core Curriculum Chest Pain
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Physical Exam

• GEN WDWN W male in min distress
• HEENT WNL, JVD
• COR NSR, Sinus Tachycardia, Sinus bradycardia,
  SEM, S3, S4,
• CHEST CTA Bilaterally, Basilar rales, rales
  throughout bilateral lung fields
• ABD Non-tender
• BACK without spinal or CVA tenderness
• EXT WNL, PVD, Pedal Edema, symmetric pulses
• RECTAL hemocult -

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Core Curriculum Chest Pain
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EKG

• ST changes
• Subendocardial ischemia
• Prinzmetals Angina

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Core Curriculum Chest Pain
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EKG - Angina
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CXR

• WNL
• Cardiomegaly
• Pulmonary congestion
• Pulmonary edema

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Core Curriculum Chest Pain
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ED Course

• Stable Angina
• Pain relieved with NTG and rest
• No change in usual anginal pattern
• No EKG changes
• No evidence of CHF

• Unstable Angina
• New onset (lt 2 months)
• Angina at rest
• Angina brought on walking lt 2 blocks
• Pain unrelieved with sublingual NTG
• NTG drip required
• Increased frequency, severity/character of pain,
  increased NTG requirements

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Core Curriculum Chest Pain
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Disposition

• Stable Angina
• Routine outpatient cardiology/medicine follow-up
• Outpatient echo, stress, catheterization to be
  determined by PMD

• Unstable Angina
• Coronary care unit
• Monitored bed

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Core Curriculum Chest Pain
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Case 3

• 23 yo white male with a recently resolved URI
  presents with a 6 hour history of constant,
  stabbing substernal chest pain made worse with
  inspiration or movement and improved when the
  patient sits up and leans forward.

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Core Curriculum Chest Pain
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PericarditisHistory/presentation

• Age all
• Sex no difference
• Duration sudden or gradual onset - constant
• Location retrosternal
• Radiation back, neck, left shoulder, arm
• Character sharp, stabbing
• Aggravated by inspiration, movement
• Relieved by leaning forward
• Associated symptoms fever, dyspnea, dysphagia

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Core Curriculum Chest Pain
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Vital Signs

• Temp WNL, low-grade temp
• HR WNL, tachycardia
• RR WNL, tachypnea
• BP WNL, hypotensive

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Core Curriculum Chest Pain
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Triage

• Medications
• Allergies
• PMHx
• PSHx
• FHx
• Cardiac risk factors
• Contraindications to thrombolytic therapy

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Core Curriculum Chest Pain
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Physical Exam

• GEN WDWN W male in min distress
• HEENT WNL, JVD
• COR WNL, pericardial friction rub
• CHEST CTA, basilar rales
• ABD soft, NT, Nml. BS
• BACK without CVA tenderness
• EXT no edema, symmetric pulses
• RECTAL hemocult -

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Core Curriculum Chest Pain
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EKG

• Evolutionary 4 stages
• Stage 1 hours to days
• Diffuse ST elevations in all leads except AVR
  V1
• Reciprocal changes in AVR and V1
• No T wave abnormality
• PR depression
• No Dysrhythmias
• Stage 2 transiently normal EKG
• Stage 3 deep Symmetrical Inversion of T waves
• Stage 4 normal EKG or permanent T wave inversions

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Core Curriculum Chest Pain
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Slide - EKG Pericarditis
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CXR

• WNL
• Increase in cardiothoracic ratio without
  pulmonary venous hypertension
• On lateral, epicardial fat pad sign in 15
• Echo/CT definitive

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Core Curriculum Chest Pain
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Tamponade
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Differential Diagnosis

• Acute Pericarditis
• Idiopathic
• Viral vs. bacterial vs.. fungal infection
• Malignancy
• Drug induced
• Connective tissue disease
• Radiation-induced
• Postmyocardial infraction (Dressler syndrome)
• Uremia
• Myxedema

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Core Curriculum Chest Pain
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ED Course

• Echocardiography procedure of choice
• Additional ancillary labs
• Streptococcal serology
• Bld cultures
• Acute and convalescent viral titers
• ANA
• TFT
• ESR

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Core Curriculum Chest Pain
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Treatment

• Etiology directed.
• Viral (majority) responds to 1-3 weeks of
  outpatient NSAIDS

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Disposition

• Outpatient
• Viral etiology
• Hemodynamically stable

• Inpatient
• Hemodynamically unstable
• All other etiologies

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Core Curriculum Chest Pain
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Case 4

• 55 yo hypertensive white male presents with a 20
  min history of severe shearing intrascapular back
  pain associated with left arm numbness and
  coolness.

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Aortic DissectionHistory/Presentation

• Age gt 50 yo
• Sex predominantly male
• Duration severe at onset, constant
• Location retrosternal, intrascapular, above and
  below the diaphragm
• Radiation dependent on path of dissection
• Character cutting, searing, ripping, tearing

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Core Curriculum Chest Pain
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Vital Signs

• Temp Afebrile
• HR variable, non-diagnostic
• RR WNL, slight tachypnea
• BP variable, non-diagnostic

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Core Curriculum Chest Pain
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Triage

• Medications
• Allergies
• PMHx
• PSHx
• FHx
• Cardiac risk factors
• Contraindications to thrombolytic therapy

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Core Curriculum Chest Pain
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Physical Exam

• GEN WDWN elderly W male in severe distress
• HEENT WNL, facial droop, asymmetric carotid
  pulses, JVD
• COR RRR w/o murmurs, S3, S4, JVD, diastolic
  murmur
• CHEST CTA Bilaterally
• ABD soft, NT, Nml. BS, pulsatile mass, bruit
• BACK w/o CVA tenderness B
• RECTAL NST, Hemocult -/
• EXT symmetric pulses, asymmetric or absent pulses

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Core Curriculum Chest Pain
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EKG

• Non-specific changes
• AMI

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Core Curriculum Chest Pain
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CXR

• Abnormal in 90 of cases
• Dilation of aortic shadow
• Intimal calcification gt 6 mm within the margin of
  the aortic shadow

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Core Curriculum Chest Pain
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CXR Aortic Dissection
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Aortic Dissection
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DeBakey Aortic Dissection Classification
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ED Course

• Emergent consult to CT surg
• BP controlled with parenteral nitroprusside to
  systolic 100-110
• HR control with parenteral Esmolol to a heart
  rate 60-80
• A-line
• Transesophogeal echo, CT chest, Aortography

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Core Curriculum Chest Pain
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Disposition

• Stanford type A
• CT surgery
• Emergent operative correction

• Stanford type B
• CCU/CT ICU
• Medical management
• Elective repair based on risk assessment (10-15
  operative mortality)

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Core Curriculum Chest Pain
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Case 5

• 44 year old, obese, black female
• sudden onset of SOB 2 hours PTA
• also complains of pleuritic chest pain
• history of hypertension and CHF
• BP 180/90 HR 110 pO2 94

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Pulmonary EmbolusHistory and physical

• Age gt 40 yo
• Sex male female
• Duration 30 min - 3- 4 days
• Location lateral lung field (classic),
  substernal, chest wall
• Radiation can mimic MI
• Character pleuritic, worse on inspiration
• Associated symptoms dyspnea (84), tachypnea
  (92), cough (53), anxiety/apprehension (59),
  syncopal episode (13), hypotension, dysrhythmia,
  shock

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Core Curriculum Chest Pain
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Vital Signs

• Temp afebrile
• gt 37.8 (43)
• HR gt100 (44)
• RR gt16 (92)
• BP WNL, shock

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Core Curriculum Chest Pain
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Triage

• Medications
• Allergies
• PMHx
• PSHx
• FHx
• PE/Cardiac risk factors
• Contraindications to thrombolytic therapy

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Core Curriculum Chest Pain
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Physical Exam

• GEN WDWN male/female in mod resp distress
• HEENT WNL, JVD
• COR RRR w/o murmurs
• Tachycardic (44), gallop (34)
• CHEST CTA B
• Rales/rhonchi/wheezes/pleural friction rub (58)
• ABD soft, NT, nml BS
• Congested liver
• BACK without CVA tenderness B
• RECTAL NST, without masses/tenderness, hemocult
  -
• EXT 2 pulses T/O, symmetric

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EKG

• Right heart strain
• Multiple areas of infarction
• Non-specific transient ST-T changes
• S1, Q3, T3 pattern

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EKG PE
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CXR

• Abnormal
• Elevated dome of one diaphragm
• Pleural effusions, atelectasis, transient
  pulmonary infiltrates
• Hampton hump
• Westermark sign

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Core Curriculum Chest Pain
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CXR PE
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CXR - PE
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Predisposing factors PE

• Cardiopulmonary disease
• Stasis of blood flow
• Alterations in coagulation
• Trauma

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Core Curriculum Chest Pain
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ABG

• A-a gradient PAO2 (alveolar)- PaO2
  (arterial)713 x FiO2-1.2 (PCO2)-PaO2
• Abnormal in 95 of confirmed PE
• Normal A-a gradient age/44
• PO2 lt 80 mm Hg

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Core Curriculum Chest Pain
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ED Course

• Lower extremity duplex 95 sensitivity/specificit
  y for detection of DVT
• V/Q Scan screening test
• Normal perfusion scan rules out possibility of PE
• Abnormal perfusion scan warrants ventilation scan
  low, intermediate, high probability
• Pulmonary angiography / lower extremity
  venograms gold standard
• Trust your clinical suspicion

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Core Curriculum Chest Pain
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V/Q Scan
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Angiogram
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Treatment

• Heparinization
• Bolus 100u/kg
• Maintenance 10u/kg q hour
• Therapeutic PTT q 4 hours 1.5-2.0 x control

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Disposition

• Home/further diagnostic testing
• Negative PE work-up

• MICU/step-down
• High suspicion / confirmed PE
• Systemic anticoagulation
• Monitoring for hemodynamic, respiratory
  compromise

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Case 6

• 72 year old white female
• lives at nursing home
• c/o altered mental status and fever
• BP 100/50 HR 110 RR 30 pO2 91

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Pneumonia

• Presentation fever, productive cough, pleuritic
  chest pain, ETOH, HIV
• CXR focal vs. diffuse infiltrative pattern
• ABG WNL, Hypoxia
• Physical Exam focal vs.. diffuse rales, rhonchi
• Disposition
• Outpatient antibiotics with close follow-up
  young healthy, non-hypoxic, single lobe
• Medical admission all others admission for IV
  antibiotics, monitoring

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Pneumonia
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Case 7

• 24 year old, thin, white male
• history of asthma
• presents with sudden onset of SOB and pleuritic
  chest pain while smoking marijuana

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Pneumothorax

• History young male, tall, thin, smoker,
  pleuritic chest pain, dyspnea, afebrile
• CXR PTX, bleb
• Physical Exam decreased breath sounds over
  affected lung field
• ED Course oxygen, if gt 15-20 PTX, chest tube
• Disposition CT Surg floor

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Core Curriculum Chest Pain
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PTX
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Pneumomediastinum
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GI Etiology

• DDX
• Esophageal reflux/spasm
• Mallory Weiss syndrome
• Biliary tract disease
• Peptic Ulcer disease
• Pancreatitis

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Core Curriculum Chest Pain
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Muscle Skeletal Etiology

• DDX
• Costochondritis
• Intercostal muscle pain
• Cervical thoracic spine pathology

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Core Curriculum Chest Pain