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Chest Pain. William Beaumont Hospital Department of Emergency Medicine. The things that kill…. Acute MI PE Pneumothorax (ptx) Aortic Dissection Esophageal Rupture (Boerhaave’s). Let’s dive right in …. Chest Pain: what is it?.

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chest pain

Chest Pain

William Beaumont Hospital

Department of Emergency Medicine

the things that kill
The things that kill…
  • Acute MI
  • PE
  • Pneumothorax (ptx)
  • Aortic Dissection
  • Esophageal Rupture (Boerhaave’s)
chest pain what is it
Chest Pain: what is it?

65 y/o male complains of substernal chest pressure and tightening that radiates to his left arm, shortness of breath, diaphoresis, and nausea that started while working in the yard.

Pmhx: HTN, high cholesterol

Soc: + tobacco

FHx: father died at 62 of MI

chest pain what is it1
Chest Pain: what is it?

86 y/o female presents with generalized weakness, mental status changes, vomiting, epigastric pain, and syncope after her last episode of vomiting.

There is no other history as the NH did not feel it was necessary to send her records.

chest pain what is it2
Chest Pain: what is it?

36 y/o obese, diabetic male presents with weakness, fatigue. shortness of breath whenever he gets off the couch, and “just not feeling right, doc.”

Pmhx: diabetes since his teens, HTN, high cholesterol

FHx: mom – HTN, dad- “had a bad heart”

acute coronary syndrome acs
Acute Coronary Syndrome (ACS)
  • Includes USA, NSTEMI, STEMI
  • Leading cause of death among adults in the US (about 1 million, 2006)
  • 6 million people present to the ER per year with chest pain, 2 million of these receive the diagnosis of ACS
  • Cost of doing business: $100-120 billion
risk factors for cad


Older Age




High Cholesterol



Artificial/early menopause







No history of MI

No history of high cholesterol



Risk factors for CAD
unstable angina usa defined
Unstable Angina (USA) Defined
  • New onset angina occurring with minimal exertion or at rest, worsening of previous angina, increased frequency or duration of attack, and resistance to previous treatment
  • USA should be treated aggressively as it may be the precursor to AMI -> Admit to step down unit, IV NTG (if CP continues), IV Heparin, aspirin
  • ECG: normal/unchanged, nonspecific ST segment changes, or T wave inversions
acute myocardial infarction ami definition
Acute Myocardial Infarction (AMI)Definition
  • Rise and fall of cardiac biomarkers with the following
    • Ischemic symptoms (critical vessel stenosis with increased myocardial work load or plaque rupture)
    • Development of q waves on ecg
    • ST segment elevation or depression (STEMI and NSTEMI)
    • Coronary artery intervention (lytics or cath lab)
  • Pathologic findings of acute MI
nstemi definition
NSTEMI Definition
  • Positive cardiac enzymes in the appropriate clinical scenario without ST elevation on the ecg
  • Ecg – normal, t wave inversions, ST segment depressions
ecg findings of acs
ECG Findings of ACS
  • Hyperacute T waves
  • ST segment elevation of 1 mm
  • ST segment depression – NSTEMI vs reciprocal changes
  • T wave inversions – initial presentation or evolving infarct
  • Q waves – may emerge in the initial hour, but usually develop at 8-12 hours
  • Normal ECG
injury patterns on the ecg
Injury Patterns on the ECG

Anterior wall MI: ST segment elevation V1-V4

Vessel: LAD

injury patterns on the ecg1
Injury Patterns on the ECG

Anterior wall MI: ST segment elevation V1-V4

injury patterns on the ecg2
Injury Patterns on the ECG

Lateral Wall MI: I, aVL, V5, V6

Vessel: variable perfusion of LAD, RCA, LCx

injury patterns on the ecg3
Injury Patterns on the ECG

Anterolateral with reciprocal changes

Vessels: LAD and 1st diagonal branch

injury patterns on the ecg4
Injury Patterns on the ECG

Inferior wall MI: II, III, aVF

Vessel: 90% RCA, 10% LCx

injury patterns on the ecg5
Injury Patterns on the ECG

Posterior Wall MI: V1-V3 depression, tall upright T, tall wide R wave, R/S ratio greater than 1

Vessel: RCA, PDA, LCx

injury patterns on the ecg6
Injury Patterns on the ECG

Inferior Wall MI with Posterior Wall MI: V1-V3 depression, tall upright T, tall wide R wave, R/S ratio greater than 1

Vessel: RCA, PDA, LCx

moving on

Moving on…

What do you want to order in addition to an ecg for a patient presenting with chest pain, suspected ACS?

initial evaluation
Initial Evaluation
  • IV, O2, monitor
  • Focused H&P
  • CBC
  • Chem 7
  • CK-MB, troponin, myoglobin
  • CXR
  • PT/PTT
  • Possible d-dimer
  • ? Repeat ecg
treatment in the ec stemi ami
Treatment in the EC: STEMI/AMI
  • Activate the AMI page and cath lab
  • ASA 325mg po – proven to save lives
  • NTG SL and gtt- reduces preload>afterload, dilates coronary arteries
  • Heparin 60 U/kg bolus then 16 U/kg/hour
  • B Blocker – decrease catecholamine driven tachycardia and contractility, therefore decreasing myocardial oxygen demand
treatment in the ec stemi ami1
Treatment in the EC: STEMI/AMI
  • Morphine – for persistent pain or anxiety to reduce O2 need, weak sympathetic blocker, preload reducer through venous dilation
  • Glycoprotein IIb/IIIA inhibitors – started in the EC or cath lab for those patients undergoing mechanical coronary intervention
  • Plavix – in consultation with the cardiologist as it prohibits CABG for 5 days
treatment in the ec stemi ami reperfusion therapy
Treatment in the EC: STEMI/AMIReperfusion Therapy
  • PCI – the 90 minute rule
    • Most people are eligible
    • Decreased risk of bleeding and stroke
    • Higher initial reperfusion rates
    • Defines coronary vasculature and allows for treatment vs. surgical referral
  • t-PA – when PCI cannot be achieved in 90 minutes or is not available at the institution
    • 0-12 hours after symptom onset
ntg be cautious
NTG: be cautious…
  • Bradycardia
  • Hypotension
  • Inferior or posterior wall MI with RV INFARCT
    • Decreased preload will cause sudden hypotension and increase infarct size
    • These patients need fluids to increase preload and help fill the malfunctioning/weakened ventricle
treatment in the ec usa nstemi
Treatment in the EC: USA/NSTEMI
  • Basically the same, but without the cath lab or fibrinolytics
  • IV, O2, monitor
  • ASA, heparin, ntg, B blocker, morphine
  • Plavix and G IIb/IIIa inhibitors potentially after discussion with cardiology
  • Admit to a monitored unit
chest pain low risk but risky enough
Chest Pain: low risk, but risky enough
  • Patients who are low risk with risk factors (silly isn’t it?), chest pain free, and have a normal ecg and enzymes
  • Observation unit for serial cardiac enzymes and ecg
  • Stress test vs. CTA
  • Cardiology consult variable
chest pain what is it3
Chest Pain: what is it?

38 y/o female presents with sudden onset of chest pain and shortness of breath shortly after retrieving her bags at the baggage claim from a flight home from Hawaii. She states that it is worse when she takes a deep breath. She also complains of this aching pain in her R leg when walking.

chest pain what is it4
Chest Pain: What is it?

80 y/o bedridden patient sent from the NH with mental status changes and hemoptysis. She is pleasant during the conversation, but has no idea why she is here. She is actively coughing and appears to have increased work of breathing.

Vitals: HR 110 BP 90/60 RR 28 sPO2 88% RA

Lungs: bibasilar rales with R mid lung rhonchi

PMHx: positive for almost everything (she is 80)

chest pain what is it5
Chest Pain: What is it?

29 y/o obese white female with history of fibromyalgia and chronic back pain presents with R neck and shoulder pain. She woke-up with it this morning, it is similar but worse than her usual aches. It hurts to move, turn, breathe, and live. She went to work today, but the aching was so bad that she had to come to the ER. Chart review shows that she was here 3 weeks ago for similar pain in her neck and lower back.

Vitals: HR 126 BP 130/90 RR 28 sPO2 90% RA

pe 2006 stats
PE – 2006 stats
  • Approximately 1 in every 500-1000 EC patients has a PE
  • ECPs correctly diagnose about 50%
  • 10% of EC patients with PE die within 30 days even when PE is promptly diagnosed and treated



Trauma or surgery in the last 4 weeks





Connective Tissue Dz

Prior PE or DVT

Signs and Symptoms

Chest Pain





HR > 100

Pulse ox < 95%

Unilateral arm or leg swelling

pe diagnosis
PE - Diagnosis
  • Basic Labs – CBC and Chem 7
  • ? Labs – ck-mb, troponin, PT/PTT
  • D dimer- low risk patients only with low pretest probability
  • CXR
    • exclude other diagnosis – CHF, pna, ptx
    • unilateral basilar atelectasis increases the probability of PE
    • Hamptom’s hump – wedge shaped infarction
    • Westermark’s sign – unilateral lung oligemia
pe cxr
Hampton’s Hump

Westermark’s Sign

pe diagnosis1
PE - Diagnosis
  • Ecg
    • Again to exclude other diagnosis
    • Most common finding is sinus tachycardia
    • T wave inversions v1-v4
    • McGinn-White Pattern – s1q3t3
    • New incomplete or complete RBBB
  • Chest CT – moderate to high risk patients or pre-test probability, positive d-dimer
pe treatment
PE - Treatment
  • Heparin unfractionated 80 u/kg bolus then 18 u/kg/hour
  • LMWH 1 mg/kg SQ q12 hours
  • Coumadin – usually started on the floor
  • IVC filter – for pts who failed anticoagulation or have contraindications
  • Thrombolytics – consider in high risk pts such as systolic hypotension, persistent hypoxemia, elevated troponin or BNP (early shock or shock)
  • Surgery – large clot burden, refractory hypotension, floating emboli in the R heart
chest pain what is it6
Chest Pain: What is it?

18 y/o tall, thin healthy male c/o sudden onset L sided CP with shortness of breath. The pain started while he was inhaling on a marijuana cigarette. It hurts more to breathe.

Vitals: HR 110 RR 28 BP 110/70 sPO2 96%

chest pain what is it7
Chest Pain: What is it?

60 y/o male with a history of severe COPD c/o increasing shortness of today that is not relieved with his home inhalers.

Vitals: HR 110 RR 28 BP 110/70 sPO2 90%

Heart: distant, tachycardic and regular

Lungs: diffuse wheezing, decreased breath sounds on the right

  • Primary Spontaneous – occurs in people without clinically apparent lung disease
    • 15/100,000 in men, 5/100,000 in women
    • Associated factors = tall, smoking, changes in ambient atmospheric pressure, genetics, MVP, Marfan’s syndrome
    • Disruption of the alveolar-pleural barrier is thought to occur when a bleb or bulla ruptures into the pleural space
  • Secondary Spontaneous – occur with known underlying pulmonary disease
    • Three times more common in men
    • Associated with any underlying pulmonary disease including infection, ILD, neoplasms, COPD, asthma, etc…
    • Weakening of the alveolar-pleural barrier occurs secondary to the underlying lung disease either from inflammation or development of bullae
  • Iatrogenic
    • Complication of intubation or aggressive BVM, central line placement, or any endoscopic procedure involving the trachea or esophagus
    • Consider in any stable patient with acute deterioration, hypoxia, or increased difficulty with ventilation
tension pneumothorax
Tension Pneumothorax
  • Positive intrapleural pressure causes compression of the mediastinum and the contralateral lung
  • Pressure exceeding 15 to 20 mm Hg impairs venous return to the heart
  • Leads to cardiovascular collapse if not treated immediately -> this is a clinical diagnosis not a radiographic one!
pneumothorax clinical presentation

Ipsilateral sharp CP


Pleuritic pain



Sinus tachycardia


Decreased breath sounds

Unilateral enlargement of the hemithorax



PneumothoraxClinical Presentation
pneumothorax diagnosis
Pneumothorax: Diagnosis
  • Clinically for tension PTX
  • CXR
    • Radiolucent band devoid of lung markings
    • Inspiratory/expiratory views
    • Lateral decubitus views in sick patients
    • Supine CXR may have deep sulcus sign
  • Thoracic Ultrasound
  • Chest CT
pneumothorax management
Pneumothorax: Management
  • Tension – needle decompression
  • Tube thoracostomy –> 20-28 F for air, 32F at least if fluid is present
  • Observation – for PTX < 20% collapse
  • Reabsorption Rate
    • 1-2% per day
    • 4-8% if on 100% NRB
chest pain what is it8
Chest Pain: what is it?

60 y/o male complains of sudden onset tearing chest pain that went up into his jaw, through to his back, and then down into his abdomen. He also vomited once, is diaphoretic, and appears very anxious.

Vitals: BP 190/120 HR 110 RR 22 sPO2 95%

aortic dissection
Aortic Dissection
  • Occurs more often in men older than 40
  • HTN is the most common risk factor
  • Associated with cardiac surgery, bicuspid aortic valve, stimulant use, and trauma
  • Age<40, associated with congenital heart disease, Marfan, Ehlers-Danlos, and giant cell arteritis
  • 44% of pts with Marfan’s will develop an aortic dissection
aortic dissection1
Aortic Dissection
  • Type A – 62% of dissections
    • Involve the ascending aorta and are therefore much more lethal
  • Type B – 38% of dissections
    • Do not involve the ascending aorta
    • Pt more likely to be older, smoke, have chronic lung disease, HTN, or atherosclerosis
aortic dissection diagnosis
Aortic Dissection - Diagnosis
  • Labs - CBC, chem7, PT/PTT, type and cross, CK-MB, troponin
  • ECG- exclude other dx, 15% may have ischemic changes -> 3% dissect back and most commonly involve the RCA, may have LVH or nonspecific ST or T wave changes
  • CXR – abnormal in 80% but nonspecific findings
  • CT scan – test of choice
  • TEE – limited by availability and operator
  • Aortography – no longer the test of choice
  • MRI- excellent test but limited by availability and instability of the patient
aortic dissection management
Aortic Dissection - Management
  • Opioids – decrease pain and sympathetic tone
  • B blockers – esmolol and labetalol
    • decrease BP and HR to decrease shearing forces
    • Should be started first unless the pt is bradycardic
  • Nipride – vasodilator, used in conjunction with a B blocker to maintain SBP 100-120
  • Hypotensive pts – measure BP in all 4 extremities to make sure it is real, IVF/Blood, immediately to OR
  • Type A -> OR (27% mortality if treated surgically vs 56% if treated medically)
  • Type B uncomplicated – 10% mortality when treated medically (32% mortality if complicated)
chest pain what is it9
Chest Pain – What is it?

22 y/o healthy male complains of chest and back pain after forcing himself to vomit. He states he had food stuck in his chest while eating at Mongolian BBQ and then forced himself to vomit for relief. He now says that his voice is hoarse, it hurts to breathe deep, and he is still very nauseated. He tried to drink some water, but this only intensified the pain.

Vitals: HR 120 BP 130/90 RR 25 sPO2 97%

esophageal rupture boerhaave s
Esophageal Rupture – Boerhaave’s
  • 15% are spontaneous with the remainder being iatrogenic from endoscopy, NGT, ETT, combitube, foreign body…
  • 90% of spontaneous ruptures occur in the distal esophagus
  • DX - CXR, gastrograffin swallow, CT
  • Management
    • IV antibiotics
    • NPO and likely NGT
    • Surgery consult
chest pain what is it10
Chest Pain – What is it?

26 y/o male c/o retrosternal, sharp CP, difficulty breathing, pain when breathing deeply, and worsening dyspnea tonight when he laid down to sleep. He states that for the last week he has had URI symptoms and low grade fever, but now feels that it has moved into his chest with the increasing pain and difficulty breathing.

Vitals: HR 110 BP 110/80 RR 24 sPO2 98%

Heart: tachycardic and regular, (+) pericardial rub

Lungs: CTA B

Bedside TTE is negative for effusion

  • Causes – infectious, injury/trauma, metabolic, systemic (RA), carcinoma, or aortic dissection
  • DX – clinical suspicion, ecg, echo
  • Echo – pericardial effusion and tamponade are worrisome complications -> pts should be put in obs or hospitalized
  • Treatment – NSAIDS, steroids for pts who cannot tolerate NSAIDS