CHEST PAIN WORKUP

Pt is a 28 year-old white male who presents to ER following a small knife wound to the chest sustained in a mugging.

c/c: “I feel like I’m dying.”HPI: Pt arrived in ER with a 1 inch stab wound

sustained to the left side of his chest which doesn’t appear to have penetrated very deeply. Pt reports he was stabbed with a knife by a mugger while outside an ATM. Pain is rated 10/10. Pt has not experienced much in the way of blood loss but he feels terrible, is breathing rapidly, and is very weak. ER survey was conducted and Pt was started on IV fluids via 2x large bore IVs.

HISTORY

PMH: None.PSH: Rotator cuff surgery on L shoulder 4 years ago.All: NKDA.Meds: Fish oil supplements.Fam: Father (HLD).Soc: No Tob, 5-7 drinks EtOH/wk, no illicit drug usage.ROS: +Chest pain, +SOB, +cough; no hemoptysis, no

abdominal pain, no nausea, no vomiting, no diarrhea, no constipation, no blood in stool, no pain on urination.

HISTORY, CONTINUED

VS (abn only): RR 21, HR 115, BP 58/78 on admit (improving with free-flow fluids and currently at 74/97).

HEENT: WNL.Neck: Evident JVD (increasing on inspiration), no

carotid bruits.Chest: No tenderness, breath sounds clear and equal

bilat.Heart: Distant heart sounds, tachycardia, normal

rhythm, normal S1/S2.Abd: Soft, non-distended, non-tender, BS+.Extr: No edema, peripheral pulses weak and

symmetric.

PHYSICAL

*Note: while there are obvious aspects of a trauma or shock work-up with this Pt, what I want you to focus on is the underlying clinical pathology you think is present.

That is to say, what’s causing this?

ANY INITIAL DIFFERENTIALS SO

FAR?

Ccommon causes of chest pain include: Aortic dissection Cardiac tamponade Massive hemothorax Pleural effusion Pneumothorax Pulmonary embolism

DIFFERENTIAL DIAGNOSES

SO, WHICH INITIAL IMAGING/LABS SHOULD WE

GET?

By far the most important imaging/labs in this work-up are: ECG Echocardiography CXR CBC/electrolytes ABG Continue monitoring VS

This is not to say you couldn’t order additional tests/labs; however, these imaging/labs will: Cover the differentials in our chest pain work-up Focus on the most serious (i.e. life-threatening) targets in our chest pain

work-up (the ones which clinically you cannot afford to miss) Help to conserve costs (typically, both our Pt and our attending will not

be happy if we order every test under the sun)

*As an aside, obviously in any instance where there has been a stabbing, etc. which arrives, police should be notified

INITIAL IMAGING/LABS

IMAGING/LAB RESULTS

Take a quick precursory glance to see if there’s anything abnormal:

Are the lungs full (i.e. not collapsed) and clear of blood/fluid?

Is there any mediastinal shift or widening?

How about the size of the heart? (Normal is <1/2 chest width)

What we’re looking for generally is to be able to rule out some of our differentials

CXR RESULT

This CXR is clearly abnormal:

Lungs are largely obscured by the heart but there does not appear to be either a pneumothorax or pleural effusion.

There is no mediastinal shift (i.e. no tension pneumothorax) or widening (no aortic dissection).

Outline of the heart is hugely enlarged and globular in shape. There is obviously some kind of effusion present here.

CXR RESULT, CONTINUED

Echo shows ventricular diastolic collapse

ECHO RESULTS

So what does our Pt’s ECG indicate? First look at leads II and V5

Does this look like a normal ECG tracing? Next, note the changes in anterolateral leads V3-V6

ECG RESULTS

Looks like we have notable QRS alternans (alternation of QRS amplitude) Look at leads II and V5 – see how the QRS height fluctuates? Hint: QRS alternans is typical of the problem we’re dealing

with

ECG RESULTS, CONTINUED

So, whittling down our differentials, we have: Aortic dissection

No mediastinal widening, no ripping/tearing chest pain radiating to back.

Cardiac tamponade Triad of hypotension, muffl ed heart sounds, and JVD (especially

increased JVD on inspiration), in addition to ventricular diastolic collapse on Echo and CXR showing a massive globular-shaped heart (due to blood in the pericardium).

Massive hemothorax There is definitely blood here, but it appears to be confined to the

area around the heart. Pleural effusion

No apparent blood in the lungs. Pneumothorax

No air in chest cavity, no mediastinal shift. Pulmonary embolism

SOB; however, no fever, no DVT risk, 0/3 on Virchow’s Triad (no hypercoagulable state, no endothelial damage, and no stasis).

DIFFERENTIAL DIAGNOSES, REVISITED

SO WHAT’S OURFINAL DIAGNOSIS?

What we’re dealing with here is cardiac tamponade.

How do we know this? Primarily due to the following triad: Muffl ed heart sounds JVD (and Kussmaul’s sign – increased JVD with inspiration),

and Hypotension

Along with: Tachycardia Narrow pulse pressure Ventricular diastolic collapse on Echo Enlarged, globular heart on CXR Pt hx of stab wound to chest

FINAL DIAGNOSIS

Cardiac tamponade occurs due to an excess amount of fluid in the pericardial sac which leads to: Decreased filling of the heart Low stroke volume (and narrow pulse pressure) Decreased cardiac output

Cardiac tamponade is typically due to: Pericarditis Stab wounds Malignancies

So, how do we treat cardiac tamponade?

CARDIAC TAMPONADE

CARDIAC TAMPONADE TREATMENT

Management of cardiac tamponade is a relatively simple process to remember:

Hospital admission with continuous cardiac monitoring IV fluids to promote volume expansion (increasing CO), and Pericardiocentesis (stick a needle into the pericardium and

suck out the excess fluid)

So, to recap remember a few key things:

Think cardiac tamponade when you see its tell-tale triad of: Muffl ed heart sounds JVD (and Kussmaul’s sign – increased JVD with inspiration), and Hypotension

Also remember cardiac tamponade is a potential occurrence following: Pericarditis Stab wounds Malignancies

Cardiac tamponade is managed with: IV fluids to promote volume expansion, and Pericardiocentesis to remove the excess fluid

IN SUMMATION

American Heart Association Available at: http://circ.ahajournals.org

Cancer Dundee Quizzes Available at:

http://cancerdundee.wordpress.com/weekly-quizz/

Heart Pearls Available at: http://www.heartpearls.com

BIBLIOGRAPHY