How to Approach a Patient with Chest Pain in Emergency Department

JOJ Case Stud 3(3 JOJCS.MS.ID.555615 (2017) 00


Introduction
Chest pain is one of most common symptoms presenting in emergency department and it is worried us because it is widely range differential diagnosis between life threatening conditions such as Acute coronary symptoms (ACS), Pulmonary Embolism (PE), Aortic dissection, pericarditis with tamponade, pneumothorax and esophageal rupture or maybe the Chest pain can be caused by non-emergent conditions such as esophageal reflux, peptic ulcer, biliary colic, muscle strain, costocondritis, pleurisy, Pneumonia and non specific chest wall pain.
It is important as emergency physicians to have approach to chest pain to able recognized life-threatening conditions from non -emergent conditions and we will learn in this chapter how to approach to patient with Chest pain.
Currently we don't have data how many patients visiting ED in Middle East;however, in USA approximately 6 million patients visit ED almost 9% [1].Which consider is second most common complain ED visit in USA.
General Approach to patient with Chest pain in Emergency Department as a general rule any chest pain is ischemic in origin until proven otherwise.

Initial approach
A. Airway, Breathing and Circulation (ABC) assessment by i.
Assessment of the airway by able to talk without distress, no obvious upper airway obstruction such tongue swelling, lip swelling, hoarseness, …etc.) ii.
Assessment of breathing (listen to the pulmonary sounds (Equal, wet (basal crackles indicate CHF).
iii.Assessment of Circulation (listen to heart sounds such as S3,4 gallop rhythm in congestive heart disease and new murmurs: mitral regurgitation murmur in papillary muscle dysfunction.

B.
Vital signs should be assessed and repeated at regular intervals for example respiratory distress with low O 2 saturation indicate pulmonary edema, ↓BP indicates cardiogenic shock), also unequal BP in both arm or pulse deficient indicate aortic dissection.vi.Asses abdomen for tenderness and pulsating mass.

Case 1
46-year-old male with DM, HTN, Coronary Artery Disease 1 year ago and Smokercomplain of chest tightness and heaviness gradual onset 3 hour ago lasting 20 minutes when he was watching TV the pain scale was 5/10, radiated to his jaw this pain associated with nausea and sweating, the pain relived by Nitro spray taken by himself but after he arrived to ED the pain started again with pain scale 10/10.ECG (Figure 1) Critical bedside actions and general approach

Juniper Online Journal of Case Studies
f. Esophageal rupture.

History and physical examination hints
a.
The chest Pain is Typical angina pain (Heaviness radiating to jaw associated with nausea and sweating), the pain is not sharping such in PE or Tearing like in aortic dissection.

b.
The Patient has cardiac risk factors (DM, HTN, CAD, Smoker and MI 1 year ago).

c.
No PE risk factors.

d.
The history not suggested any history of Esophageal rupture.

e.
Physical exam not lead to cardiogenic shock or pulmonary edema. f.
No sign of pneumothorax in exam.
g. Pulses all equal for four limbs and no inequality in BP in both arm which not going with aortic dissection.h.
ECG suggested Inferior MI, no sign of pericarditis in ECG.

Emergency diagnostic tests and interpretation
a.
ECG suggested Inferior MI, no sign of pericarditis in ECG.

b.
Portable CXR: normal which is role out pneumothorax and aortic dissection (no wide mediastinum).c.
Troponin I is high which is suggested MyocardiaIschemia.

d.
Bed side echocardiography there is hypokinetic in inferior wall and no sign of cardiac temponade.

Bedside test
a.
12 lead ECG for (Anterior, inferior and lateral myocardial infarction AND 15lead ECG (posterior myocardial infarction) to detect any ST elevation in 2 contiguous leads: STEMI.

b.
Ischemic changes (STdepression, T inversion and Q wave), ECG is more useful as 'rule in' than 'rule out' ECG in Acute Myocardial Infarction 50% sensitivity, 90% specificity.

Laboratory tests
a.
Blood cardiac markers:Troponin I or T rise within 3-6H and then remain elevated for about one week.

b.
Serial testing, at least 6H after symptom onset improves sensitivity.

c.
In ACS an increased troponin is a marker for increased risk of AMI and death.

d.
Does NOT diagnose cardiac ischemia.

Imaging modalities
a. Chest X-ray: To look for heart failure and evaluate for other cause of chest pain such as Aortic Dissection.

Emergency treatment
Aspirin should be given immediately: Great benefit, little risk, Give minimum of 182 mg.

Rapid decisions on reperfusion:
Based on ECG only (PCI vs Fibrinolysis).Referral: Cardiology to be consulted

Case 2
30-year-old male had an open reduction and internal fixation (ORIF) of right ankle fracture 2 weeks ago, c/o sudden onset of chest pain today this is pleuritic sharp chest pain associated with short breath increased during inspiration [2][3][4][5].12 ECG shows: sinus tachycardia, T inversion V2,3 and 4, deep S lead 1 and Q and T inversion in lead 3, St elevation V1 and V4R suggested pulmonary embolism.(Figure 4).Critical bedside actions and general approach a.

Initial assessment at triage
2 Supply and monitor bed.

c.
Vitally stable except he is tachycardia (HR 120).

d.
Quick history which suggested that patient went major surgery 2 weeks ago and was immobilized 2 weeks andPhysical examination shows.

e.
Chest exam: Equal air entry, no wheeze or crackles.

g.
There is calf swelling in Right site of surgery, pulses for 4 limbs present and equal.h.
To do 12 lead ECG shows sinus tachycardia, T inversion V2,3 and 4, deep S lead 1 and Q and T inversion in lead 3, St elevation V1 and V4R suggested pulmonary embolism.

i.
Patient in Pain need analgesia.f.Esophageal rupture.

History and physical examination hints
a.
The chest Pain is atypical angina pain (sharp, pleuritic chest pain increased by inspiration and associated with short of breath, noradiation), the pain is not angina pain OR no tearing pain as in aortic dissection.

b.
There is PE risk factors (major surgery, immobilization 2 weeks).c.
The history not suggested any history of Esophageal rupture.

d.
Physical exam not lead to pneumonia no crackles in chest exam.

e.
No sign of pneumothorax in exam.
f. Pulses all equal for four limbs and no inequality in BP in both arm which not going with aortic dissection.g.
ECG suggested PE, no sign of pericarditis in ECG.

Bedside test
a.
12 lead ECG for PE sign in ECG S1Q3T3 sign (prominent S wave in lead I, Q wave and inverted T wave in lead III) is a sign of acute corpulmonale (acute pressure and volume overload of the right ventricle because of pulmonary hypertension) and reflects right ventricular strain (2).

Juniper Online Journal of Case Studies b.
Other ECG findings noted during the acute phase of a PE include new right bundle branch block (complete or incomplete), rightward shift of the QRS axis, ST-segment elevation in V1 and aVR, generalized low amplitude QRS complexes, atrial premature contractions, sinus tachycardia, atrial fibrillation/flutter, and T wave inversions in leads V1-V4 (3).

c.
The ECG is often abnormal in PE, but findings are neither sensitive nor specific for the diagnosis of PE. (4), The greatest utility of the ECG in a patient with suspected PE is ruling out other life-threatening diagnoses (e.g., acute myocardial infarction).ii.

Laboratory tests
No study has shown survival benefit, but very difficult to study.

Disposition a.
If there is suspicious of PE, we need to do pre-test probability, there is Multiple systems for doing this.

b.
Most widespread and validated is Well's score.vii.There is there radio-to radio pulsation delay.
viii.There are abdominal and bilateral femoral bruits, with absent distal pulses.
ix.To do 12 lead ECG shows no ST, T wave changes, no sign of MI. x.
Portable CXR shows wide mediastinum, no sign of CHF, pneumothorax or pneumonia.

History and physical examination hints
a.
The chest Pain is sudden onset central ripping chest pain radiating to back as in aortic dissection, the pain it is not angina pain.

b.
There is Risk factors, HTN, CAD, smoker and age.
c.The history not suggested any history of Esophageal rupture.

d.
Physical exam not lead to pneumonia no crackles in chest exam.

e.
No sign of pneumothorax in exam.
f. Pulses delay in radio -radio pulsation and different BP in both arm and abdominal and bilateral.femoral bruits, with absent distal pulses with going with aortic dissection.g.
ECG no sign of ischemic changes, no sign of pericarditis in ECG.

h.
Patient in Pain need analgesia.

Emergency diagnostic tests and interpretation
a.
12 lead ECG shows no ST, T wave changes, no sign of MI. b.
Portable CXR shows wide mediastinum, no sign of CHF, pneumothorax or pneumonia.ii.Beta blockers are first line (Labetalol and Esmolol).

Figure 1
Figure 1 Antiplatelet options: Heparin (LMW v unfractionated) clopidogrel.Symptomatic/pain control: GTN Vasodilator, also reduces preload Can give SL or IV and Morphine for pain control and reduce anxiety and stress.Secondary prevention: B-Blocker, statins and ACE inhibitor.Disposition decision a) Assess the risk stratification by using TIMI score (Figure 2 & 3).

Figure 4
Figure 4 a.ECG suggested Pulmonary embolism, no sign of pericarditis in ECG.b.Portable CXR: normal which is role out pneumothorax and aortic dissection (no wide mediastinum) there is sign of Right ventricle enlargement and strain and no sign of cardiac temponade.
Figure 5 c. Cardiac enzyme was negative role out MI. d.D-Dimer was negative.e. Bed side Echo no sign of temponade.Bedside test a.CXR-Widened mediastinum, abnormal aortic knob, pleural effusions.b.Not sensitive (25% have wide mediastinum's).c.Bedside US -evaluate aorta and look at heart to r/o tampanode.
a.Laboratory tests to role out other differential diagnosis such as MI, PE.Imaging modalitiesa.CXR-Widened mediastinum, abnormal aortic knob, Cardiac Thoracic surgery early.b)Blood pressure control i.Goal SBP 120-130 mmHg.

Table 1 :
History of Chest Pain.

of Chest Pain Pressure, Tightness, Or Heaviness, Sharp. Tearing or Ripping
Admit for further evaluation,add beta blockers, ACE inhibitors.Follow cardiac enzyme levels.If MI ruled out, Exercise stress test before discharge.