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Chest Pain ED Evaluation - PowerPoint PPT Presentation


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Garik Misenar, MD, FACEP. Chest Pain ED Evaluation. Objectives. U nderstand differential diagnosis of chest pain L earn key points in the evaluation of chest pain Know the key findings associated with chest pain Discuss disposition of potentially cardiac chest pain. Chest Pain.

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Presentation Transcript
objectives
Objectives
  • Understand differential diagnosis of chest pain
  • Learn key points in the evaluation of chest pain
  • Know the key findings associated with chest pain
  • Discuss disposition of potentially cardiac chest pain
chest pain
Chest Pain
  • Nearly 6 million ED patients annually
  • 5% of all ED visits
pathophysiology
Pathophysiology
  • Afferent fibers from heart, lungs, great vessels, and esophagus enter same thoracic dorsal ganglia
  • Visceral fibers produce indistinct quality of pain
  • Dorsal segments overlap three segments above and below
  • Pain anywhere from jaw to epigastrium
differential diagnosis
Differential Diagnosis
  • Cardiovascular
  • Pulmonary
  • Gastrointestinal
  • Musculoskeletal
  • Neurologic
  • Psychogenic
rapid assessment
Rapid Assessment
  • Vital signs
  • EKG within 10 minutes
  • Chest x-ray
immediate stabilization
Immediate stabilization
  • Acute MI
  • Esophageal rupture
  • Thoracic aortic aneurysm
  • Pulmonary embolus
  • Pneumothorax
slide8
Pain
  • Description
  • Activity at onset
  • Location
  • Radiation
  • Duration
  • Aggravating/alleviating
problems
Problems
  • Similar episodes in past
    • Misdiagnosis or misattribution
  • Risk factors
    • Important for populations
other history
Other history
  • Syncope/Near syncope
  • Dyspnea
  • Hemoptysis
  • Nausea/vomiting
  • Diaphoresis
physical exam
Physical Exam
  • Respiratory distress
  • Diaphoresis
  • Vital signs
  • Heart sounds
  • Lung sounds
  • Abdominal exam
  • Extremity exam
slide12
EKG
  • New injury
    • Acute MI
    • Aortic dissection
  • New ischemic pattern
    • Ischemia
    • Coronary spasm
  • Diffuse elevation
    • Pericarditis
chest x ray
Chest X-Ray
  • Pneumothorax
    • Simple vs. Tension
    • Esophageal rupture
  • Widened mediastinum
    • Aortic Dissection
  • Effusion
    • Esophageal rupture
  • Enlarged cardiac silhouette
    • Pericarditis
  • Pneumomediastinum
    • Esophageal rupture
laboratory studies
Laboratory studies
  • D-dimer?
    • Marker of fibrinolysis
    • Negative rules out if low risk for PE
    • Positive test does NOT mean PE/DVT
      • Acute Coronary Syndrome, Aortic dissection, Atrial fibrillation, DIC/VICC, Infection, Malignancy, Pre-eclampsia, Sickle cell, Stroke, Trauma
    • False positive:
      • Elderly, pregnancy, post-op, smokers, African-Americans, decreased mobility
laboratory studies1
Laboratory studies
  • Troponin I and T
    • Identify patients with highest risk of adverse outcome
    • Sensitivity at 4 hours is 60%, nearly 100% at 12 hours
  • CK-MB
    • Sensitivity at 4 hours is 80%; 93% at 6 hours
    • Secondary role to troponin currently
high risk
High risk
  • Elevated troponin
  • New ST depression
  • Recurrent ischemia
  • Heart failure with ischemia
  • Hemodynamic instability
  • PCI in last 6 months
  • Previous CABG
high risk1
High risk
  • Observation vs. Intervention
intermediate risk
Intermediate risk
  • Chest pain resolved
  • Possible ischemic changes
  • Normal cardiac markers
intermediate risk1
Intermediate risk
  • Observation vs. early intervention
low risk
Low risk
  • Chest pain resolved
  • Nondiagnostic EKG
  • Normal cardiac markers
low risk1
Low risk
  • Observation
  • Repeat EKG and cardiac markers
  • Provocative testing
  • If all normal, discharge
summary
Summary
  • There are numerous diagnoses which can cause chest pain
  • Rapidly assess and treat imminent life threats
  • Look for key points on the history and physical
  • Use additional studies to help differentiate among diagnoses
  • Additional testing required for potentially cardiac chest pain