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Differential Diagnosis of Chest Pain

Differential Diagnosis of Chest Pain. Christopher A. Gee, MD Division of Emergency Medicine University of Utah Health Sciences Center September 29, 2009. Chest Pain. 1 in 20 patients presenting to ED complain of Chest Pain

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Differential Diagnosis of Chest Pain

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  1. Differential Diagnosis of Chest Pain Christopher A. Gee, MD Division of Emergency Medicine University of Utah Health Sciences Center September 29, 2009

  2. Chest Pain • 1 in 20 patients presenting to ED complain of Chest Pain • Extremely broad differential with a range of diagnoses from the catastrophic, to the mundane • All diagnoses have a “classic” presentation, but most patients don’t present typically • Key point is to know patterns and treat life threats immediately (tension ptx) • Have mental picture of each dx

  3. Chest Pain • Chest Pain is big concern to pts • Plentiful • Easy to say pt has nothing • On the other hand, its easy to lose the forest for the trees (cookbook medicine) • Need “Happy Medium” • Make a decision- Gestalt

  4. Pathophysiology • Like HA, has a similar final pathway • Afferents from heart, lungs, great vessels, esophagus all enter the same thoracic dorsal ganglia • Dorsal segments overlap 3 segments above and below, therefore have wide area pain can manifest • Visceral fibers give burning, aching, stabbing, or pressure character to pain • Look for patterns

  5. Pathophysiology

  6. Chest Pain

  7. Chest Pain

  8. Getting Started • Don’t let pt sit in WR • Chest Pain=“O, MI!” (O2, Monitor, IV) • Assess VS (Always check and recheck VS- bounceback) • Address life threats

  9. What is This? Something you don’t ever want to see

  10. Getting Started • MOAN • Morphine/ Monitor • Oxygen • Aspirin • Nitroglycerin • EKG, CXR (portable)- Why not? • Labs, CT, etc, etc, etc

  11. History • 80-90% of info pertinent to ddx is obtained from good H & P • Character: • Squeezing, Crushing, PressureACS • TearingAortic Dissection • Sharp, stabbing Pulmonary or GI • Activity at onset (exertional, at rest/ Gradual?) • Radiation (arm, jaw, back) • Duration- Maximal at onset? (aortic dissection) • Alleviating factors? Prior hx of pain? Assoc symptoms? • Why today?

  12. Case 1

  13. Case 1 • 40 yo Indian Male BIBA after trying to defend convenience store from marauding kids • Sustained SW to mid abd and right posterior chest • VS 80/40, 115 100/65, 100 with 2 L NS • Suddenly becomes hypotensive, tachycardic • What do you do? • ABCs!! What do you want to know? • +JVD, tracheal shift, decbs, hyperresonance, sq air

  14. What’s the Dx? • Tension pneumothorax • 14 G angiocath in 2ndintercostal space at MCL, watch for woosh of air • Mandates a tube thoracostomy • Clinical dx • Incidence unclear- 2.5-18/100,000

  15. Case 2

  16. Case 2 • Mr B: 110 yo male p/w sob and chest pain • Hx: Billionaire with advanced lung cancer. Sitting at rest had sudden cp, worse with deep breath • Hypoxic, tachycardic, reproducible cp • What’s dx? • Pulmonary Embolism

  17. PE • Until 1930’s was almost universally fatal • True estimate of incidence difficult (DVT and PE=0.2% per yr in general population) • Estimated that 400K are missed every year, resulting in death of 100K that would have survived • 10% die within first 60 min • 650K deaths per year making PE 3rd most common cause of death in the US

  18. PE • Pain abrupt and maximal at start. Pleuritic • Dyspnea and apprehension. Hemoptysis <20% • Pregnancy, ocp, heart dz, cancer, prior dvt or pe are all risk factors • Resp rate >16, tachycardia, rales, pulmonic 2nd sound may be present

  19. PE • How do you dx • Angio? • Labs? • Ddimer? • ABG? • CT? • US of LE? • VQ? • EKG/ CXR?

  20. PE- ABG • Will pts with PE consistently have low PO2? No

  21. CXR-PE • Cardiac Enlargement- 27% • Pleural Effusion- 23% • Elevated Hemidiaphragm- 20% • Pulmonary artery enlargement- 19% • Atelectasis- 18% • Parenchymal Pulmonary Infiltrates- 17% • Normal- 24%

  22. CXR-PE Rare Findings • Hampton’s Hump • Westermark’s Sign

  23. EKG-PE • Tachycardia and non-specific ST seg and T wave changes • Right sided heart strain (only 20% have this) • P pulmonale • RAD • A fib • S1 Q3 T3

  24. EKG-PE

  25. Ddimer-PE • Unfortunately, characteristics of this test limit its use alone in ruling in or ruling out PE • Test result must be considered in light of pretest probability • Will miss about 7% of cases with VTE (depends on particular test) • Should only be used in low probability pts. Can effectively exclude PE in low prob pt

  26. Well’s Critieria • A clinical scoring system for diagnosis of PE • Suspected DVT 3 • Alternative dx less likely 3 • Pulse > 100/min 1.5 • Immobilization/surgery w/in 4 weeks 1.5 • H/ope/dvt 1.5 • H/ohemoptysis 1 • H/o malignancy 1 • Total >6=High pretest prob (66.7%) 2-6= Moderate pretest prob (20.5% <2= Low pretest prob (3.6%)

  27. VQ Scan • Essentially a screening test. However, it is most often non-diagnostic • At least 70% don’t have quality of info needed to make dx • Radioisotope labeled albumin is infused and compared to ventilation. Mismatch indicates PE • Safe in pregnancy (fetal exposure is 50 mrem, 1/10 allowable exposure) • Abnormal lungs prevent diagnostic study • Reported as NL, near-NL, indeterminate, low/medium/high prob

  28. VQ Scan

  29. CT Scan • Not as sensitive as a nl VQ • Can miss peripheral PE’s in small vessels (95% sens for segmental and 75% sens for subsegmentalPes) • Advantages include speed and ability to diagnose other problems

  30. CT-PE

  31. PE • What if you really don’t think the pt has a PE? Do you have to do a test? • PERC Rule (PE R/O Criteria) • Age <50 years • HR <100 bpm • RA O2 sat >94% • No prior DVT or PE • No recent trauma or surgery • Nnohemoptysis • No exogenous estrogens • No Unilateral leg swelling • If the patient has none of the criteria specified, the pretest probability is less than 2%, and the patient will not benefit from an evaluation for PE • Was derived from a large multicenter database and has been validated in several studies

  32. PE Treatment • Heparin 80-100 U/kg bolus, then 18 U/kg/hr • LMWH • Need bridge of heparin before therapeutic on coumadin, due to paradoxical hypercoagulability at start of coumadin therapy • Lytics can be used for hemodynamic instability or severe RV dysfunction on ECHO • Surgery- largely replaced by Lytics • Vena Caval Filters to prevent recurrent PE’s in those unable to use heparin

  33. Case 3

  34. Case 3 • 45 yo male alcoholic found intoxicated and vomiting. c/o chest pain • Friend reports pt had eaten large meal when started drinking • Pt is diaphoretic and dyspneic • BP 80/60, HR 120 • What does pt have?

  35. Boerhaave’s Syndrome • Esophageal rupture after gluttonous eating and then vomiting • First named by Hermann Boerhaave after a dutch admiral who died of it- Baron Jan von Wassenaer

  36. Boerhaave’s Syndrome Often have sq emphysema Hamman’s Crunch Incidence is 12.5/ 100K Often considered very late High Mortality

  37. Case 4

  38. Case 4 • 42 yo obese male smoker, p/w 2 hours of tearing substernal chest pain • Pain was maximal at onset and radiates to pt’s back • Only medical hx is HTN • Exam shows 190/111, HR 100. Pt c/o headache and vision changes. Pt’s cranial nerves are not nl. • UE pulses are not equal

  39. Portable CXR • Aortic Dissection

  40. Aortic Dissection

  41. Aortic Dissection • Stanford A and B. A involves the arch and needs surgery

  42. Aortic Dissection • Incidence of 0.5-1/100K • Mortality exceeds 90% if misdiagnosed • Frequently missed (online chat rooms about AD) • If have symptoms above and below diaphragm, or any neurologic symptoms with chest pain, be very suspicious • Also, be suspicious in younger pt that comes in with weakness or aphasia like big stroke. Could be AD • Whenever have pt with headache, neck or face pain, consider AD

  43. AD- Treatment • Blood pressure control is of paramount importance • Start with B blocker (Esmolol) to control rate and then add nitroprusside- this decreases sheer forces on the aortic wall • Control pt’s pain, give O2, foley • Ddimer?

  44. Almost Done. . .

  45. Case 5 • CF= 40 yo male p/w crushing sscp while performing on stage • Pt diaphoretic, vomiting, pale • Obviously dyspneic • Clutching chest • Given ntg by EMS, mild relief • Pain radiates to left arm

  46. ACS • Risk Factors: • h/o cad • +FH • Men >33, women over 40 • DM • HTN • Smoking • Sedentary lifestyle • Postmenopausal • Obesity • Can have USA, NSTEMI, STEMI

  47. ACS • CAD contributes to 50% of all deaths in US • 1 million deaths per year • Historically missed 3-5% (improving) • Account for 20% of malpractice losses in EM • OMI, MOAN, CXR and EKG

  48. EKG

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