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Chest Pain ED Evaluation

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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Chest Pain ED Evaluation

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  1. Garik Misenar, MD, FACEP Chest PainED Evaluation

  2. 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

  3. Chest Pain • Nearly 6 million ED patients annually • 5% of all ED visits

  4. 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

  5. Differential Diagnosis • Cardiovascular • Pulmonary • Gastrointestinal • Musculoskeletal • Neurologic • Psychogenic

  6. Rapid Assessment • Vital signs • EKG within 10 minutes • Chest x-ray

  7. Immediate stabilization • Acute MI • Esophageal rupture • Thoracic aortic aneurysm • Pulmonary embolus • Pneumothorax

  8. Pain • Description • Activity at onset • Location • Radiation • Duration • Aggravating/alleviating

  9. Problems • Similar episodes in past • Misdiagnosis or misattribution • Risk factors • Important for populations

  10. Other history • Syncope/Near syncope • Dyspnea • Hemoptysis • Nausea/vomiting • Diaphoresis

  11. Physical Exam • Respiratory distress • Diaphoresis • Vital signs • Heart sounds • Lung sounds • Abdominal exam • Extremity exam

  12. EKG • New injury • Acute MI • Aortic dissection • New ischemic pattern • Ischemia • Coronary spasm • Diffuse elevation • Pericarditis

  13. Pulmonary EmbolusS1Q3T3

  14. Chest X-Ray • Pneumothorax • Simple vs. Tension • Esophageal rupture • Widened mediastinum • Aortic Dissection • Effusion • Esophageal rupture • Enlarged cardiac silhouette • Pericarditis • Pneumomediastinum • Esophageal rupture

  15. 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

  16. 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

  17. High risk • Elevated troponin • New ST depression • Recurrent ischemia • Heart failure with ischemia • Hemodynamic instability • PCI in last 6 months • Previous CABG

  18. High risk • Observation vs. Intervention

  19. Intermediate risk • Chest pain resolved • Possible ischemic changes • Normal cardiac markers

  20. Intermediate risk • Observation vs. early intervention

  21. Low risk • Chest pain resolved • Nondiagnostic EKG • Normal cardiac markers

  22. Low risk • Observation • Repeat EKG and cardiac markers • Provocative testing • If all normal, discharge

  23. 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

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