Rosen & Barkin's 5-Minute Emergency Medicine Consult (152 page)

• Cardiac exam for murmurs, rub, decreased heart sounds, or extra heart sounds
  
• Chest exam for decreased breath sounds, rales, wheezing
  
• Extremity exam for decreased pulses, pulsus paradoxus
  
• Skin exam for lesions of herpes zoster
  
• Abdominal exam for tenderness, rebound, guarding
  

EKG:

• Inexpensive and available
  
• Obtain and interpret within 10 min of arrival
  
• Serial EKG can be useful in patients with high concern for ACS and a negative initial EKG.
  
• See specific etiologies.
  

• Lab testing should be individualized to the patient and the presentation, based on the risk of potential life threats.
  
• See “Cardiac Testing.”
  
• D
  -Dimer:
  
  • Sensitive but poor specificity for physical exam
    
  • Indicated for low-risk patient if there is an indication to rule out pulmonary embolus
    
  • Controversial use as a screening test for aortic dissection
    

• CXR:
  
  • Pneumothorax
    
  • Pneumonia
    
  • CHF
    
  • Aortic dissection:
    
    • Widened mediastinum seen in ∼55–62% of patients
      
    • A pleural effusion is found in ∼20% of patients.
      
    • Apical capping
      
    • Aortic knob obliteration
      
    • A normal chest radiograph is found in 12–15% of patients.
      
  • Acute pericarditis:
    
    • Usually normal unless massive effusion enlarges cardiac silhouette
      
  • Esophageal rupture:
    
    • Usually will show mediastinal air
      
    • May have left pleural effusion
      
• Helical CT scan:
  
  • Pulmonary embolism
    
  • Sensitive for aortic dissection
    
• Ventilation/perfusion scan:
  
  • Useful in pulmonary embolus
    
  • Must have normal CXR
    
• Angiography:
  
  • Pulmonary embolism; although rarely done
    
  • Useful in dissection, especially in stable patients
    
• US:
  
  • Test of choice for pericardial and valvular disease
    
  • Transesophageal Echo can be used in diagnosis of aortic dissection, especially in unstable patients and those unable to tolerate contrast.
    
  • Right ventricular dilation and hypokinesia is suggestive for pulmonary embolus and can be used to guide therapy
    
  • Bedside transthoracic Echo can be used to quickly discover significant pericardial effusion, pneumothorax, and pleural effusion
    

See “Etiology.”

TREATMENT

• Therapeutic interventions should be guided by the patient’s presentation, risk factors, and past history.
  
• If a cardiac life threat is suspected:
  
  • IV access
    
  • Cardiac monitoring
    
  • EKG
    
  • Oxygen
    
  • Baby aspirin/Full aspirin
    
  • Pain control:
    
    • Nitrates
      
    • Morphine
      

As guided by the patient’s presentation:

• ABCs
  
• IV
  
• Oxygen
  
• Cardiac monitoring
  

• IV, oxygen, and monitoring
  
• EKG
  
• Treatment varies based on suspected etiologies.
  

Dependant on etiology

FOLLOW-UP

Dependent on the risk for life-threatening cardiopulmonary etiologies

Safe if patient is deemed to have low-risk etiology of chest pain

Follow-up with primary care physician on low-risk chest pain for outpatient assessment

Patient should be instructed to return if:

• Chest discomfort lasts >5 min
  
• Chest discomfort gets worse in any way
  
• History of angina, and discomfort not relieved by usual medicines
  
• Shortness of breath, sweats, dizziness, vomiting, or nausea with chest pain or chest discomfort
  
• Chest discomfort moves into your arm, neck, back, jaw, or stomach
  

• Caution in only ordering a single biomarker
  
• Using response to medications as a diagnostic tool
  
• Not using serial EKG in patients with suspected ACS or repeating EKGs when patients have recurrent chest pain
  

• Anderson JL, Adams CD, Antman EM, et al. 2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
  Circulation
  . 2011;123(18): e426–e579.
  
• Body R, Carley S, Wibberley C, et al. The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes.
  Resuscitation.
  2010; 81(3):281–286.
  
• Courtney DM, Kline JA, Kabrhel C, et al. Clinical features from the history and physical examination that predict the presence or absence of pulmonary embolism in symptomatic emergency department patients: Results of a prospective, multicenter study.
  Ann Emerg Med
  . 2010;55(4): 307–315.
  
• Hoffmann U, Truong QA, Schoenfeld DA, et al. Coronary CT angiography versus standard evaluation in acute chest pain.
  N Eng J Med.
  2012;367(4):299–308.
  
• Upadhye S, Schiff K. Acute aortic dissection in the emergency department: diagnostic challenges and evidence-based management.
  Emerg Med Clin North Am.
  2012;30(2):307.
  

CODES

• 786.50 Chest pain, unspecified
  
• 786.51 Precordial pain
  
• 786.59 Other chest pain
  

BASICS

• Significant source of morbidity and mortality in US
  
• ∼12 thoracic trauma victims per million population per day
  
• ∼33% of these injuries require hospital admission.
  
• Directly responsible for 20–25% of all deaths attributed to trauma
  
• Contributing cause of death in 25% of patients who die from other traumatic injuries
  

• Common mechanisms of injury include:
  
  • Motor vehicle collisions (70–80%)
    
  • Motorcycle collisions
    
  • Pedestrians struck by a motor vehicle
    
  • Falls from great heights
    
  • Assaults
    
  • Blast injuries
    
  • Sports-related injuries
    
• Injuries can result from direct blunt force to the chest or from forces related to rapid deceleration.
  

DIAGNOSIS

• Obvious contusion, wound, or other defect of the chest wall
  
• Paradoxical chest wall movement suggests flail chest segment.
  
• Usually occurs in combination with other injuries
  
• Hypotension
  
• Some patients with severe intrathoracic injuries, such as traumatic aortic disruption, may have
  no
  visible external signs of trauma.
  

• Time of injury
  
• Mechanism of injury
  
• Estimates of motor vehicle accident (MVA) velocity and deceleration
  
• Loss of consciousness
  
• Chest pain
  
• Pain with deep inspiration or cough
  
• Dyspnea
  

• Unilaterally absent breath sounds
  
• Crepitus or subcutaneous air in the chest wall
  
• Decreased or absent breath sounds
  
• Tenderness to palpation on the chest wall
  
• Jugular venous distention
  
• Tracheal deviation away from midline
  
• Hyper-resonance to percussion on involved side