Chest pain

Y'all better know how treat a heart attack or we're going to have a problem

located in the internal organs, blood vessels, and visceral pleura; enters CNS at multiple levels, difficult to locate, described as ache, pressure, tightness, heaviness, discomfort

Tell me about Visceral Pain Fibers

located in dermis/parietal pleura, enters CNS at specific levels and maps to specific areas in parietal cortex, dermal distribution, sharp-type pain that is precisely located

Tell me about Somatic Pain fibers

ACS, PE, Boerhaave syndrome, Aortic dissection, tension pneumothorax, cardiac tamponade/effusion

6 causes of chest pain to always consider in EM

vital w/ pulse oximetry and defib pads; O2 supplementation, IV access, serial EKGs, ASA/nitro (depends on EKG result)

Shotgun orders for Chest Pain

Cardiac, Pulmonary, Neuro, Abdomen, +pertinent systems

Physical exam for cardiac emergencies

aortic aneurysm until r/o (get a CT angio)

Chest pain with a neuro deficit is a…

CBC, Coags (INR, PT, PTT), CMP, Trop, maybe CK, CKMB, lipase, Hcg, U/A, urine tox screen, MAYBE ABG/VBG, D-dimer, stool guaiac, blood/urine culture

Labs for Chest pain homies

CXR (2 view if we can), chest CT, chest CT with PE protocol (CT lung angiogram), CT aortogram (dissection), V/Q scan, DVT U/S

Imaging for Chest pain homies

Young, healthy, no comorbidities (D/C with close follow up)

Which chest pain patients get discharge?

STEMI, NSTEMI, Unstable Angina (at rest), Stable Angina (with exerbation)

Types of Acute Coronary Syndrome encompasses…

Activate the Cath lab/thrombolytic checklist, 324 mg ASA, nitro (up to 3x doses), Oxygen (if under 92%), Morphine (if the nitro didn’t work), CXR (r/o dissection)

Gameplan for a STEMI in the ER (same thing for a suspected NSTEMI)

Phosphodiesterase inhibitors w/in 24 hrs, SBP < 90, bradycardia, RV infarct (elevation in inferior leads with reciprocal changes in V5-V6)

C/I to nitro

contact cardio, anticoag with enoxaparin/heparin, admit the patient

Once we confirm an NSTEMI (confirmed with elevated troponins or those trending upward), what is the game plan?

Follow up (can the patient be seen in 3 days by cardio), stress testing, cardiac CT (CAC scores)

Disposition for suspected angina depends on

History, EKG, Age, Risk Factors, Troponin (if positive they aint leaving)

HEART Score risk stratification (0-3 discharge with follow/up or stress; 4-6 admit; 7+ interventional candidiate)

Pulmonary Embolism (PE)

Chest pain w/ or w/o SOB (maybe just SOB) is a characteristic of

Wells (start here), PERC (if wells less than 4)

PE diagnostic algorithms

Clinical signs/symptoms of a DVT, PE is the most likely, Tachycardia, immobilization at least 3 days or surgery in the last 4 weeks, previously diagnosed DVT/PE, hemoptysis, malignancy w/ treatment within 6 months or palliative

Tell me the Wells Criteria

50 y/o+, tachycardia, less than 95% on RA, unilateral leg swellings, hemoptysis, recent surgery/trauma, prior PE/DVT, female hormone use

Tell me the PERC criteria (any positive means we are ordering a D-Dimer)

CT pulmonary angio (🏆), V/Q scan (preg/allergies), Venous U/S (DVT - if you find a DVT and they have chest pain, treat the PE girl)

Imaging for PEs

Anticoags (enoxaparin 1 mg/kg BID), admit/discharge based on HESTIA/PESI

Gameplan for a confirmed PE

Aortic Dissection

What occurs after a violation of the intima that allows blood to enter the media and dissect between the intimal and adventitial layers - associated with Marfans

sudden onset of ripping/tearing chest pain that radiates through the upper back

Presentation of a Aortic Dissection

unilateral pulse deficit, neurological deficits, blood pressure discrepancy (low sensitivity)

Physical Exam findings of Aortic Dissection

involves ascending aorta (type A - emergency), limited to descending aorta (type B)

Stanford classification of Aortic Dissection

Widened mediastinum, abnormal aortic contour, pleural effusion

CXR findings of a Aortic Dissection

CT Angio

Imaging of choice for aortic dissection

Call a surgeon, Antihypertensives (esmolol - for a quick on/off)

Treatment plan for Aortic Dissection

Boerhaave syndrome

A full thickness perforation of the esophagus after a sudden rise in intra-esophageal pressure - usually due to a sudden, forceful emesis (most common), coughing, straining, seizures, childbirth

Hx of sudden onset, sharp, substernal chest pain after vomiting, tachycardia, fever, dyspneic, diaphoresis, maybe crepitus in the neck or chest

Findings in Boerhaave Syndrome

CT with oral water soluble contrast

Imaging for Boerhaave Syndrome

Call a surgeon, prepare to treat a tension pneumo

Game plan for Boerhaave Syndrome

Pneumothorax

Air accumulation in the pleural space that is more common in tall, slender males

Smoking, chronic lung diseases

Risk factors of a pneumothorax

decreased breath sounds, hyperresonance to percussion on the ipsilateral side

Findings in a pneumothorax

observation, oxygen development, (chest tube in the big ones)

Gameplan for a small (under 3 cm) stable, spontaneous pneumo (1-3% will convert to a tension pneumo)

Tension Pneumo

If air continues to accumulate in the pleural space causing a mediastinal shift, what do we have on our hands?

Hemodynamic instability, tachypnea, hypotension, decreased oxygen sat, JVD, tracheal deviation

Findings in a tension pneumo

emergency needle thoracostomy chest decompression followed by a chest tube

Gameplan for tension pneumo

CLINICAL (if you see it on x-ray you missed it)

Diagnostics for tension pneumo?

pleural effusion

Accumulation of fluid in the pleural space

dyspnea, pleuritic chest pain, infectious signs and symptoms, decreased breath sounds, hypo-resonance

Findings in pleural effusions

Admit, Drain/culture, Therapeutic thoracentesis with drainage of 1.0 to 1.5 L (if dyspnea at rest), empyemas require thoracostomy tubes

Game plan for pleural effusions

Pneumonia

An infectious accumulation in the alveoli

Fever, cough, back pain, pleuritic chest pain, N/V (if irritating the diaphragm)

Findings in Pneumonia

Lobar consolidation on CXR (🏆), CT for complicated cases

Imaging for Pneumonia

CURB-65, PORT score, PSI (pneumonia severity index)

Disposition for pneumonia in the ED depends on

Amoxicillin + Azithro/doxy (healthy), Augmentin + Azithro/doxy (comorbidities or recent Abx), Levofloxacin/Moxifloxacin/Lefamulin (non-beta lactam or structural lung disease); corticosteroids if signs of shock

Abx for pneumonia (community acquired, we’re in the ER not inpatient duh)

Sharp, severe, constant, substernal pain that may radiate to back, neck, or shoulders but is relieved by leaning forward and worsens when lying down, pericardial friction rub, diffuse ST-elevation with PR depression, fever, malaise, tachy

Findings in pericarditis

Admit, NSAIDs, ASA (post-MI), Colchicine (prevents recurrence), corticosteroids (if refractory), treat the underlying, no anticoags, pericardiectomy (last resort)

Gameplan for pericarditis

Pericardial effusion

Fluid accumulation in the pericardial sac due to trauma (usually) characterized by sharp, substernal chest pain, dyspnea, orthopnea, dysphagia, and/or hoarseness

muffled/distant cardiac sounds, JVD, pulsus paradoxus, hypotension

Findings in pericardial effusions

post-cardiac cath, renal failure, trauma, malignancy

Risk factors for pericardial effusions

Bedside U/S (sub-xyphoid or parasternal view) 🏆, CXR (enlarge radiopaque sillhouette)

Diagnostics for pericardial effusions

hypotension, muffled heart sounds, JVD

Cardiac tamponade is characterized by Beck’s triad, what is this?

pericardiocentesis (needle place sub-xyphoid) followed by a pericardial window

Game plan for cardiac tamponade

ADMIT

An patient who is not hemodynamically stable…