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Chest PainED Evaluation
Garik Misenar, MD, FACEP
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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
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Chest Pain
Nearly 6 million ED patients annually 5% of all ED visits
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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
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Differential Diagnosis
Cardiovascular Pulmonary Gastrointestinal Musculoskeletal Neurologic Psychogenic
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Rapid Assessment
Vital signs EKG within 10 minutes Chest x-ray
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Immediate stabilization
Acute MI Esophageal rupture Thoracic aortic aneurysm Pulmonary embolus Pneumothorax
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Pain
Description Activity at onset Location Radiation Duration Aggravating/alleviating
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Problems
Similar episodes in past Misdiagnosis or misattribution
Risk factors Important for populations
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Other history
Syncope/Near syncope Dyspnea Hemoptysis Nausea/vomiting Diaphoresis
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Physical Exam
Respiratory distress Diaphoresis Vital signs Heart sounds Lung sounds Abdominal exam Extremity exam
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EKG
New injury Acute MI Aortic dissection
New ischemic pattern Ischemia Coronary spasm
Diffuse elevation Pericarditis
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Pulmonary EmbolusS1Q3T3
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Chest X-Ray
Pneumothorax Simple vs. Tension Esophageal rupture
Widened mediastinum Aortic Dissection
Effusion Esophageal rupture
Enlarged cardiac silhouette Pericarditis
Pneumomediastinum Esophageal rupture
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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
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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
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High risk
Elevated troponin New ST depression Recurrent ischemia Heart failure with ischemia Hemodynamic instability PCI in last 6 months Previous CABG
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High risk
Observation vs. Intervention
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Intermediate risk
Chest pain resolved Possible ischemic changes Normal cardiac markers
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Intermediate risk
Observation vs. early intervention
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Low risk
Chest pain resolved Nondiagnostic EKG Normal cardiac markers
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Low risk
Observation Repeat EKG and cardiac markers Provocative testing If all normal, discharge
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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