Chest Pain Emergencies EMET PROGRAM DR IAN TURNER FACEM

Approach  Red flags  Differential diagnosis  Clinical clues to diagnosis  Best initial tests to clarify diagnosis  Diagnostic tests  Temporising treatment  Definitive management

Case 1  48 male  Fit and well  Sudden onset of severe lower chest pain radiating through to his back with dizziness and clamminess  Looks unwell, 37.2C, BP 115/72, HR 88, RR 22, SaO2 97%

Red flags  Usual well male coming to an ED  Severity of pain  Through to back  Dizziness/clamminess

Differential diagnoses  AMI  Dissection  Perforated viscus  Pancreatitis

Clinical Clues  AMI – angina, exercise tolerance, family history, pain type, clutching chest, CV risk factors  Dissection – pain type, CTD, blood pressure differential, hypertension, neuro findings  Perforated viscus – abdominal findings, GI bleeding, hypotension, exposure risk factors  Pancreatitis – exposure risk factors  Cholecystitis – relation to food, abdominal findings

Initial Tests  ECG  CXR

Diagnostic Tests  AMI – the ECG  Dissection – CT, echo, angiogram  Perforated viscus – CXR, CT  Pancreatitis – lipase, CT

Temporising Treatment  Resuscitation appropriate to differential diagnosis  AMI – analgesia, GTN  Dissection – analgesia, BP management  Perforated viscus – analgesia, fluid resus, IV ABs  Pancreatitis – analgesia, fluid resus

Definitive Management  AMI - reperfusion  Dissection – BP control +/- surgery  Perforated viscus – IV ABs, theatre  Pancreatitis – fix cause, NGT, fluid management, glucose control, enteral feeding

Case 2  72 female  Type II diabetes, rheumatoid arthritis  Chest discomfort radiating towards right shoulder with nausea and breathlessness at rest  Speaking in short sentences, 37.4C, BP 105/82, RR 24, SaO2 91%

Red flags  Immunosuppression  The elderly patient  Breathlessness

Differential diagnoses  AMI (+/- pulmonary oedema)  Pneumonia  PE

Clinical Clues  AMI – angina, exercise tolerance, family history, pain type, clutching chest, CV risk factors  Pneumonia – infective features, immunosuppression, sick contacts  PE – risk factors

Initial Tests  ECG  CXR  Blood gas

ABG  pH 7.46  PaCO2 25  PaO2 61  HCO3 21  SaO2 90%

ABG  pH 7.42  PaCO2 29  PaO2 123  HCO3 20  SaO2 99%

Diagnostic Tests  AMI – the ECG  Pneumonia – CXR (CT)  PE – CTPA, V/Q, echo

Temporising Treatment  Resuscitation appropriate to differential diagnosis  AMI (+/- pulmonary oedema) – analgesia, GTN, oxygen therapy  Pneumonia – analgesia, oxygen therapy  PE – analgesia, oxygen therapy, IV fluids

Definitive Management  AMI – reperfusion  Pulmonary oedema – GTN, NIV, diuresis  Pneumonia – IV ABs  PE – anticoagulation, thrombolysis, embolectomy

Case 3  37 female  Central sharp chest pain radiating to neck  Episode of collapse  Breast cancer  36.5C, BP 110/72, RR 22, SaO2 95%

Red flags  Syncope  Malignancy

Differential diagnoses  PE  Pericarditis +/- effusion  Bony metastasis

Clinical Clues  PE – risk factors  Pericarditis +/- effusion – pain pattern, exam findings  Bony metastasis – exam findings, malignancy history

Initial Tests  ECG  CXR  Blood gas

Diagnostic Tests  PE – CTPA, V/Q, echo  Pericarditis +/- effusion – echo, CT  Bony metastasis – CXR, CT, bone scan

Temporising Treatment  PE – analgesia, oxygen therapy, IV fluids  Pericarditis +/- effusion – analgesia, IV fluids  Bony metastasis – analgesia

Definitive Management  PE – anticoagulation, thrombolysis, embolectomy  Pericarditis +/- effusion – drainage, window  Bony metastasis – XRTx, bisphosphonates