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20/20: CHEST PAIN WORKUP
Published on Oct 10, 2016
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20/20: CHEST PAIN WORKUP
8 Steps to Chest Pain in the ED
Chest pain is a diagnosis EM physicians are certain to see on an almost daily basis.
As the front line of health care workers responding to such crisis' it becomes essential we know how to respond to these cases quickly and efficiently.
As the front line of health care workers responding to such crisis' it becomes essential we know how to respond to these cases quickly and efficiently.
Photo by Brandon Heyer
1 - triage WORKUP
- Vital Signs - Temp, HR, BP, O2 sat
- EKG - ST elevation in 2 contiguous leads? (compare to old EKG)
- Tx - ASA 325mg, NTG, IVF, O2*, cardiac monitoring
- Overall assessment; "thick slicing"
Initial assessment always begins in triage. All patients get vitals, EKG, possible MI prophylaxis is suspicion is high, and an overall assessment of severity.
* Routine oxygen therapy in acute MI settings is a common practice. Whereas hypoxemic patients undoubtedly benefit from oxygen insufflation, the level of evidence for this practice in normoxemic patients is insufficient to determine its efficacy and safety (Shuvy, 2013).
Oxygen therapy in acute coronary syndrome: are the benefits worth the risk? You have access
Mony Shuvy, Dan Atar, Philippe Gabriel Steg, Sigrun Halvorsen, Sanjit Jolly, Salim Yusuf, Chaim Lotan
DOI: http://dx.doi.org/10.1093/eurheartj/eht110 1630-1635 First published online: 3 April 2013
* Routine oxygen therapy in acute MI settings is a common practice. Whereas hypoxemic patients undoubtedly benefit from oxygen insufflation, the level of evidence for this practice in normoxemic patients is insufficient to determine its efficacy and safety (Shuvy, 2013).
Oxygen therapy in acute coronary syndrome: are the benefits worth the risk? You have access
Mony Shuvy, Dan Atar, Philippe Gabriel Steg, Sigrun Halvorsen, Sanjit Jolly, Salim Yusuf, Chaim Lotan
DOI: http://dx.doi.org/10.1093/eurheartj/eht110 1630-1635 First published online: 3 April 2013
Photo by Rosmarie Voegtli
2 - History - OPQRST+
- O - when start? what were you doing? getting worse/better/same?
- P - what makes better? worse?
- Q - dull, stabbing? pounding? pleuritic?
- R - radiating to arms or back?
- S - scale 1-10? worst ever? similar to previous episodes?
- T - when do you notice pain? how long does it last? Constant?
- + - n/v? SOB? ever before?
- Getting worse/better/same?
Further workup starts with a comprehensive history and physical exam to rule out serious causes of chest pain
Photo by Dan Queiroz
3 - PMH/PSH/MEDS/SH/ALLERGIES
- PMH - HTN, angina, GERD, prior MI, stress testing?
- PSH - recent surgery or procedures?
- Meds - Aspirin? Blood thinners? HTN meds? Statin?
- SH - Smoke? IVDU? Last use? Job? Stress? Travel hx?
- Allergies - do they cause chest pain or SOB?
In assessing history, don't forget about cardiac risk factors, recent surgeries, drug use, travel history, stress inducers.
Photo by Curtis Gregory Perry
4 - VITALS
- Repeat vitals!
- Temp - fever? (1 degree = 10 bpm)
- BP - volume up (HTN) or down (HoTN)?
- HR - tachycardic (>100)?
- RR - tachypnea (>20)?
- O2 sat - hypoxic (
Vital signs should be repeated whenever you suspect change in patients condition. No one will ever fault you for checking. Always verify any deviations from patients baseline and whether they've taken any HTN or cardiovascular medications prior to arrival.
Photo by bgolub
5 - Physical exam
- General Appearance - distressed? toxic?
- HEENT, Neck - Pupils? oral mucosa? skin? JVD?
- Lungs - decreased BS? wheezing? Tender to palp?
- Heart - murmurs? S1, S2?
- Abdomen - tender? abdominal bruit?
- Extremities - Calf swelling/tender? Pulses b/l?
Physical exam focuses on cardiac and pulmonary involvement, investigating any signs of deviations from norm.
Photo by Joaquin Villaverde Photography
6 - Labs, IMAGING
- Labs - CBC (anemia), Chem 10, Coags, Troponins/CK-MB
- EKG, repeat
- CXR
- CT w/ IV contrast
- LE doppler
- ECHO
Further labs and imaging are driven by clinical suspicion. Though most all patients receive non-invasive EKG, CXR, and cardiac enzyme testing, only some patients will need a CT, Echo, LE Doppler
Photo by Pulmonary Pathology
7 - DDX CP
- Cardiac - UA/NSTEMI/STEMI*, Prinzmetal angina, pericarditis, c.tamponade*, myocarditis, aortic dissection*, CHF
- Pulm - PNA, pleuritis, tension PTC*, PE*
- GI - GERD, esophageal spasm, MW-tear, esophageal rupture*, pancreatitis
- MSK - costochondritis, OA/radiculopathy
- Misc - herpes zoster, anxiety, sickle cell disease
Although the list is extensive and most causes of chest pain benign, it is essential that the deadly causes of chest pain be ruled out with a proper H&P and workup.
*"Deadly 6" that must get picked up by EM physician!
*"Deadly 6" that must get picked up by EM physician!
Photo by .:Adry:.
8 - Disposition
- Is this life-threatening?
- Does this require further workup?
- Home or admission?
Disposition is what makes the EM physician. You're the one who decides if serious causes of chest pain can be ruled out and the patient sent home, if further workup is necessary, consults needed, or admission to hospital. Remember, this is a decision that could save a patients life or result in a thousand dollar workup. Choose wisely.
Photo by alex@faraway
Summary - CP WORKUP
- Initial assessment is key in ED!
- Hx can often make the diagnosis
- PE, labs, imaging - confirm clinical suspicion
- "Thick slice" - always rule out deadly causes of chest pain
- Disposition could save a life; be thorough!
Photo by Chocolate Geek
