Chest PainED Evaluation

Garik Misenar, MD, FACEP

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

Nearly 6 million ED patients annually 5% of all ED visits

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

Cardiovascular Pulmonary Gastrointestinal Musculoskeletal Neurologic Psychogenic

Rapid Assessment

Vital signs EKG within 10 minutes Chest x-ray

Immediate stabilization

Acute MI Esophageal rupture Thoracic aortic aneurysm Pulmonary embolus Pneumothorax

Pain

Description Activity at onset Location Radiation Duration Aggravating/alleviating

Problems

Similar episodes in past Misdiagnosis or misattribution

Risk factors Important for populations

Other history

Syncope/Near syncope Dyspnea Hemoptysis Nausea/vomiting Diaphoresis

Physical Exam

Respiratory distress Diaphoresis Vital signs Heart sounds Lung sounds Abdominal exam Extremity exam

EKG

New injury Acute MI Aortic dissection

New ischemic pattern Ischemia Coronary spasm

Diffuse elevation Pericarditis

Pulmonary EmbolusS1Q3T3

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

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 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

Elevated troponin New ST depression Recurrent ischemia Heart failure with ischemia Hemodynamic instability PCI in last 6 months Previous CABG

High risk

Observation vs. Intervention

Intermediate risk

Chest pain resolved Possible ischemic changes Normal cardiac markers

Intermediate risk

Observation vs. early intervention

Low risk

Chest pain resolved Nondiagnostic EKG Normal cardiac markers

Low risk

Observation Repeat EKG and cardiac markers Provocative testing If all normal, discharge

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