Differential Diagnosis of Chest PainChristopher A. Gee, MDDivision of Emergency MedicineUniversity of Utah Health Sciences CenterSeptember 29, 2009

Chest Pain1 in 20 patients presenting to ED complain of Chest PainExtremely broad differential with a range of diagnoses from the catastrophic, to the mundaneAll diagnoses have a “classic” presentation, but most patients don’t present typicallyKey point is to know patterns and treat life threats immediately (tension ptx)Have mental picture of each dx

Chest PainChest Pain is big concern to ptsPlentifulEasy to say pt has nothingOn the other hand, its easy to lose the forest for the trees (cookbook medicine)Need “Happy Medium”Make a decision- Gestalt

Organ System Critical Dx Emergent Dx Nonemergent Dx

Cardiovascular

AMICoronary IschemiaAortic Dissection

USACoronary SpasmPrinzmetal’sCocaine InducedPericarditisMyocarditis

Valvular Heart DzASMVPHCM

Pulmonary PETension PTX

PTXMediastinitis

PNAPleuritisTumorPneumomediastinum

GI Esophageal Rupture

Esophageal tearCholecystitisPancreatitis

Esophageal SpasmGERDPUDBiliary Colic

MS Muscle strainRib fxArthritisTumorCostochondritis

Neurologic Spinal root compressionThoracic OutletHerpes zoster, PHN

Other PsychologicalHyperventilation

PathophysiologyLike HA, has a similar final pathwayAfferents from heart, lungs, great vessels, esophagus all enter the same thoracic dorsal gangliaDorsal segments overlap 3 segments above and below, therefore have wide area pain can manifestVisceral fibers give burning, aching, stabbing, or pressure character to painLook for patterns

Pathophysiology

Chest Pain

Chest Pain

Getting StartedDon’t let pt sit in WRChest Pain=“O, MI!” (O2, Monitor, IV)Assess VS (Always check and recheck VS- bounceback)Address life threats

What is This?

Something you don’t ever want to see

Getting StartedMOAN

Morphine/ MonitorOxygenAspirinNitroglycerin

EKG, CXR (portable)- Why not?Labs, CT, etc, etc, etc

History80-90% of info pertinent to ddx is obtained from good H & PCharacter:

Squeezing, Crushing, PressureACSTearingAortic DissectionSharp, 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?

Case 1

Case 140 yo Indian Male BIBA after trying to defend convenience store from marauding kidsSustained SW to mid abd and right posterior chestVS 80/40, 115 100/65, 100 with 2 L NSSuddenly becomes hypotensive, tachycardicWhat do you do?ABCs!! What do you want to know?+JVD, tracheal shift, dec bs, hyperresonance, sq air

What’s the Dx?Tension pneumothorax14 G angiocath in 2nd intercostal space at MCL, watch for woosh of airMandates a tube thoracostomyClinical dxIncidence unclear- 2.5-18/100,000

Case 2

Case 2Mr B: 110 yo male p/w sob and chest painHx: Billionaire with advanced lung cancer. Sitting at rest had sudden cp, worse with deep breathHypoxic, tachycardic, reproducible cpWhat’s dx?Pulmonary Embolism

PEUntil 1930’s was almost universally fatalTrue 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 survived10% die within first 60 min650K deaths per year making PE 3rd most common cause of death in the US

PEPain abrupt and maximal at start. PleuriticDyspnea and apprehension. Hemoptysis <20%Pregnancy, ocp, heart dz, cancer, prior dvt or pe are all risk factorsResp rate >16, tachycardia, rales, pulmonic 2nd sound may be present

PEHow do you dxAngio?Labs?

Ddimer?ABG?

CT?US of LE?VQ?EKG/ CXR?

PE- ABGWill pts with PE consistently have low PO2? No

PO2 PE incidence below PO2

PE incidence above PO2

80 mm Hg 45/101 (44.6%) 9/19 (47.4%)70 mm Hg 39/87 (44.8%) 15.33 (45.5%)65 mm Hg 29/69 (42%) 25/51 (49%)

CXR-PECardiac Enlargement- 27%Pleural Effusion- 23%Elevated Hemidiaphragm- 20%Pulmonary artery enlargement- 19%Atelectasis- 18%Parenchymal Pulmonary Infiltrates- 17%Normal- 24%

CXR-PE Rare FindingsHampton’s Hump

Westermark’s Sign

EKG-PETachycardia and non-specific ST seg and T wave changesRight sided heart strain (only 20% have this)

P pulmonaleRADA fibS1 Q3 T3

EKG-PE

Ddimer-PEUnfortunately, characteristics of this test limit its use alone in ruling in or ruling out PETest result must be considered in light of pretest probabilityWill 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

Well’s CritieriaA clinical scoring system for diagnosis of PE

Suspected DVT 3Alternative dx less likely 3Pulse > 100/min 1.5Immobilization/surgery w/in 4 weeks 1.5H/o pe/dvt 1.5H/o hemoptysis 1H/o malignancy 1

Total >6=High pretest prob (66.7%) 2-6= Moderate pretest prob (20.5% <2= Low pretest prob (3.6%)

VQ ScanEssentially a screening test. However, it is most often non-diagnosticAt least 70% don’t have quality of info needed to make dxRadioisotope labeled albumin is infused and compared to ventilation. Mismatch indicates PESafe in pregnancy (fetal exposure is 50 mrem, 1/10 allowable exposure)Abnormal lungs prevent diagnostic studyReported as NL, near-NL, indeterminate, low/medium/high prob

VQ Scan

CT ScanNot as sensitive as a nl VQCan miss peripheral PE’s in small vessels (95% sens for segmental and 75% sens for subsegmental Pes)Advantages include speed and ability to diagnose other problems

CT-PE

PEWhat 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 yearsHR <100 bpmRA O2 sat >94%No prior DVT or PENo recent trauma or surgeryNno hemoptysisNo exogenous estrogensNo 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 PEWas derived from a large multicenter database and has been validated in several studies

PE TreatmentHeparin 80-100 U/kg bolus, then 18 U/kg/hrLMWHNeed bridge of heparin before therapeutic on coumadin, due to paradoxical hypercoagulability at start of coumadin therapyLytics can be used for hemodynamic instability or severe RV dysfunction on ECHOSurgery- largely replaced by LyticsVena Caval Filters to prevent recurrent PE’s in those unable to use heparin

Case 3

Case 345 yo male alcoholic found intoxicated and vomiting. c/o chest painFriend reports pt had eaten large meal when started drinkingPt is diaphoretic and dyspneicBP 80/60, HR 120What does pt have?

Boerhaave’s SyndromeEsophageal rupture after gluttonous eating and then vomitingFirst named by Hermann Boerhaave after a dutch admiral who died of it- Baron Jan von Wassenaer

Boerhaave’s SyndromeOften have sq emphysema

Hamman’s Crunch

Incidence is 12.5/ 100K

Often considered very late

High Mortality

Case 4

Case 442 yo obese male smoker, p/w 2 hours of tearing substernal chest painPain was maximal at onset and radiates to pt’s backOnly medical hx is HTNExam shows 190/111, HR 100. Pt c/o headache and vision changes. Pt’s cranial nerves are not nl.UE pulses are not equal

Portable CXR

Aortic Dissection

Aortic Dissection

Aortic DissectionStanford A and B. A involves the arch and needs surgery

Aortic DissectionIncidence of 0.5-1/100KMortality exceeds 90% if misdiagnosedFrequently missed (online chat rooms about AD)If have symptoms above and below diaphragm, or any neurologic symptoms with chest pain, be very suspiciousAlso, be suspicious in younger pt that comes in with weakness or aphasia like big stroke. Could be ADWhenever have pt with headache, neck or face pain, consider AD

AD- TreatmentBlood pressure control is of paramount importanceStart with B blocker (Esmolol) to control rate and then add nitroprusside- this decreases sheer forces on the aortic wallControl pt’s pain, give O2, foley Ddimer?

Almost Done. . .

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

ACSRisk Factors:

h/o cad+FHMen >33, women over 40DMHTNSmokingSedentary lifestylePostmenopausalObesity

Can have USA, NSTEMI, STEMI

ACSCAD contributes to 50% of all deaths in US1 million deaths per yearHistorically missed 3-5% (improving)Account for 20% of malpractice losses in EMOMI, MOAN, CXR and EKG

EKG

EKG

TreatmentCath!Lytics

STE>1mm in 2 leadsPain <6-12 hoursNew LBBB

Contraindications:Active bleeding, major surgery or trauma in 3 weeks, neurosurgery or stroke within 3 mos, prolonged or traumatic cpr, BP>180/110, Head bleed, noncompressible vascular puncture

TreatmentASA! Improves outcomesB blockade, improves myocardial oxygen consumption. Can be given within first dayHeparin

WorkupECHO-regional wall motion abnl- 88-94% sens and spec of 50-75% in pt treated within 12 hours of symptom onsetStress Test- graded exercise 60-70% sensAngioEnzymes- Can r/o infarction, but not hypoperfusion or variable lesion. USA will be negative

Thanks!!