국민보험공단 일산병원 응급의학과 R2 노재훈

Epidemiology  approximately 6 million visits per year.  70% prove not to have an acute coronary event  0.4%-4.0% of patients with AMI are sent home from the ED  doubling their mortality compared to those admitted  This issue of Emergency Medicine Practice  provides a focused approach to the initial evaluation of chest pain patients

 Current clinical policies Risk stratification protocols have been applied to the ED population, but none of these is ideal serial serum markers, serial electrocardiography, and selective stress testing.

Differential diagnosisof chest pain.

Prehospital Care  Obtain and transmit ECGs and pertinent history via cell phone or fax  Reduce the time  Goal “door-to-needle” time is less than 30m “door-to-balloon” time is 60-90m

Emergency Department Evaluation  Triage rapidly identify immediately transport to acute care area of the ED Standing orders  establishment of Iv access  oxygen administration and/or pulse oximetry  cardiac monitoring, an immediate 12-lead ECG  chest radiography ECG interpreted within 10 minutes

 The Initial Clinical Examination Serum markers, continuous ST segment monitoring, improved imaging technology, and computer protocols the initial history, physical examination, and ECG  the corner stone

History  Cardiac Question Two important piece of history  Age and Gender  Further refined based on Symptom

 Character of pain the importance of the character of pain is decidedly schizophrenic radiating to the left arm, right shoulder, or both arms, as well as patients with diaphoresis  more likely to have an AMI pleuritic, sharp or stabbing, positional, or reproduced with palpation  decrease likehood of having an AMI

 Risk factor traditional cardiac risk factors  diabetes mellitus, hypertension, smoking, hypercholesterolemia, and family history predict development of CAD over decades—not the likelihood of ACS in the setting of acute chest pain in women diabetes and family history were associated with increased relative risk In men the absence of risk factors does not exclude acute cardiac ischemia as an etiology for the patient’s pain.

 Medications and Drug use anti-anginal or anti-arrhythmic drugs. recent cocaine use

Non-ACS Condition History  Aortic dissection Most common risk factor  Man, seventh decade of life, Hypertension  Marfan’s syndrome, atherosclerosis, prior dissection, or known aneurysm Character  Sudden in onset, worst ever, sharp or tearing  Pain that Radiating to back

 Pulmonary Embolism variable and nonspecific ranging from dyspnea and fatigue to severe pleuritic chest pain and syncope Painless dyspnea  important to note Pleuritic chest pain, dyspnea, hemoptysis  embolic pulmonary infarction much more common in hospitalized than ambulatory patients

 Other conditions Classic boehaave’s syndrome  complain of pain on swallowing, and recently intoxicated Pericarditis  refers to the neck and acromial region and worsens with inspiration, swallowing, and lying supine

Physical Examination limited use in identifying stable patients with ACS or AMI since abnormal findings are rare.  Vital Signs critically important in the evaluation of patients with chest pain(e.g Hypotension +chest pain) Fever should lead to the consideration of noncardiac sources of chest pain Tachycardia is a nonspecific sign  early pericarditis or myocarditis Bradycardia  conduction defects, right coronary artery occlusions Oxygen saturation is normal in one quarter of patients with PE

 Head And Neck Examination Kussmaul’s sign  pericardial tamponade, right heart failure or infarction, PE, or tension pneumothorax Subcutaneous air  pneumomediastinum or pneumothorax

 Pulmonary Examination evidence of respiratory distress,including nasal flaring, intercostal retractions, and accessorymuscle use Percussion  effusions and pneumothorax auscultation  unilateral absence of breath sounds  Wheezing and rale

 Cardiac Examination  A new murmur  papillary muscle rupture from retrograde aortic dissection  S3 gallop  congestive heart failure  pericardial rub  pericarditis  Beck’s triad(distant heart sounds, jugular venous distention, and pulsus paradoxus)  proximal aortic dissection with impending pericardial tamponade

 Chest Wall Examination the clinician must consider life-threatening causes of chest pain.  Examination Of The Extremities evidence of edema, thrombosis, or pulse deficit  Examination Of The Pulses symmetry and quality Pulse deficits are most common in type A dissections (ascending aorta)

 Neurologic Examination a nonspecific finding Altered mental status  associated with any cause of chest pain that leads to hemodynamic instability and cerebral hypoperfusion

Diagnostic Studies  Electrocardiography single most important diagnostic test in the evaluation of patients with chest pain useful in disease processes ranging from PE to AMI The initial ECG is insensitive in identifying acute coronary syndromes  diagnostic changes in 20%-50% of patients Tall and narrow (peaked) T waves may be the earliest sign of AMI Repeat ECG if the patient has persistent ischemic- type pain or a change in symptoms

 The ECG And Pulmonary Embolism T-wave inversion in the anterior precordial leads is the earliest change in patients with pulmonary hypertension from PE Incomplete right bundle branch block and sinus tachycardia are found more commonly in patients with PE.

Radiographic Tests Another useful and accessible test  Pneumothorax And Pneumomediastinum identified by chest radiography  Pulmonary Embolism Hampton’s hump (a wedge-shaped infarct downstream from the emboli) Westermark’s sign (prominent pulmonary hilum with peripheral oligemia) Fleischner’s sign (dilated sausageshaped pulmonary artery)

 Aortic Dissection The egg-shell sign on chest radiograph is fairly specific for dissection

 Echocardiography very useful in the bedside evaluation of unstable patients in whom the differential diagnosis includes aortic dissection, PE, and AMI Transesophageal echocardiography is very sensitive in the identification of aortic dissection

 Contrast-Enhanced Computed Tomography For Acute Coronary Syndrome & Pulmonary Embolism has changed the way medicine  Ventilation/Perfusion Scans favored as the initial test in suspected PE.

Laboratory Tests  Complete Blood Count And Electrolyte Panels CBC rarely affect clinical decision-making A baseline creatinine level is useful in the older or compromised patient who requires a contrast-enhanced study  e.g the renal transplant patient suspected of PE who has a creatinine of 3.0 may be better served by a V/Q scan than a contrastenhanced spiral CT. Routine screening with chemistry panels in low-risk patients is not recommended the interpretation of cardiac stress testing may be influenced by electrolyte abnormalities, particularly potassium and magnesium.

 Arterial Blood Gas Alveolar-arterial oxygen gradient in predicting PE A normal alveolararterial gradient does not exclude the diagnosis of PE.  D-dimer & alveolar dead space the evaluation of suspected PE.