Chest Pain William Beaumont Hospital Department of Emergency Medicine Shanna Jones, MD

Chest PainChest PainWilliam Beaumont HospitalWilliam Beaumont Hospital

Department of Emergency MedicineDepartment of Emergency Medicine

Shanna Jones, MDShanna Jones, MD

The Things That Kill…The Things That Kill…

Acute MIAcute MI Pulmonary Embolus (PE)Pulmonary Embolus (PE) Pneumothorax (PTX)Pneumothorax (PTX) Aortic DissectionAortic Dissection Esophageal Rupture (Boerhaave’s)Esophageal Rupture (Boerhaave’s)

Let’s dive right Let’s dive right inin……

Chest Pain: What is it?Chest Pain: What is it?

65 y/o male complains of substernal 65 y/o male complains of substernal chest pressure and tightening that chest pressure and tightening that radiates to his left arm, shortness of radiates to his left arm, shortness of breath, diaphoresis, and nausea that breath, diaphoresis, and nausea that started while working in the yard.started while working in the yard.

PMHx: HTN, high cholesterolPMHx: HTN, high cholesterolSoc: + tobaccoSoc: + tobaccoFHx: father died at 62 of MIFHx: father died at 62 of MI


86 y/o female presents with generalized 86 y/o female presents with generalized weakness, mental status changes, weakness, mental status changes, vomiting, epigastric pain, and syncope vomiting, epigastric pain, and syncope after her last episode of vomiting.after her last episode of vomiting.

There is no other history as the NH did There is no other history as the NH did not feel it was necessary to send her not feel it was necessary to send her records.records.


36 y/o obese, diabetic male presents with 36 y/o obese, diabetic male presents with weakness, fatigue. shortness of breath weakness, fatigue. shortness of breath whenever he gets off the couch, and whenever he gets off the couch, and “just not feeling right, doc.”“just not feeling right, doc.”

PMHx: diabetes since his teens, HTN, high PMHx: diabetes since his teens, HTN, high cholesterolcholesterol

FHx: Mom – HTN; Dad – “had a bad heart”FHx: Mom – HTN; Dad – “had a bad heart”

Acute Coronary Syndrome Acute Coronary Syndrome (ACS)(ACS)

Includes USA, NSTEMI, STEMIIncludes USA, NSTEMI, STEMI Leading cause of death among adults in Leading cause of death among adults in

the US (about 1 million, 2006)the US (about 1 million, 2006) 6 million people present to the ER per 6 million people present to the ER per

year with chest painyear with chest pain 2 million of these receive the diagnosis of 2 million of these receive the diagnosis of

ACSACS Cost of doing business: $100-120 billionCost of doing business: $100-120 billion

Risk Factors for CAD – Risk Factors for CAD – TypicalTypical

MaleMale Older AgeOlder Age TobaccoTobacco HTNHTN DMDM High CholesterolHigh Cholesterol FHxFHx CocaineCocaine Artificial/early menopauseArtificial/early menopause

Risk Factors for CAD – Risk Factors for CAD – AtypicalAtypical

DMDM ElderlyElderly FemaleFemale NonwhiteNonwhite DementiaDementia No history of MINo history of MI No history of high cholesterolNo history of high cholesterol CHFCHF CVACVA

Unstable Angina (USA) Unstable Angina (USA) DefinedDefined

New onset angina occurring with New onset angina occurring with minimal exertion or at rest, worsening minimal exertion or at rest, worsening of previous angina, increased of previous angina, increased frequency or duration of attack, and frequency or duration of attack, and resistance to previous treatmentresistance to previous treatment

ECG: normal/unchanged, nonspecific ST ECG: normal/unchanged, nonspecific ST segment changes, or T wave inversionssegment changes, or T wave inversions

Acute Myocardial Infarction Acute Myocardial Infarction (AMI)(AMI)

DefinitionDefinition Rise and fall of cardiac biomarkers with Rise and fall of cardiac biomarkers with

the followingthe following Ischemic symptoms (critical vessel stenosis Ischemic symptoms (critical vessel stenosis

with increased myocardial work load or plaque with increased myocardial work load or plaque rupture)rupture)

Development of Q waves on ECGDevelopment of Q waves on ECG ST segment elevation or depression (STEMI & ST segment elevation or depression (STEMI &

NSTEMI)NSTEMI) Coronary artery intervention (lytics or cath lab)Coronary artery intervention (lytics or cath lab)

NSTEMI DefinitionNSTEMI Definition

Positive cardiac enzymes in the Positive cardiac enzymes in the appropriate clinical scenario without appropriate clinical scenario without ST elevation on the ECGST elevation on the ECG

ECG – normal, T wave inversions, ST ECG – normal, T wave inversions, ST segment depressionssegment depressions

ECG Findings of ACSECG Findings of ACS Hyperacute T wavesHyperacute T waves ST segment elevation of 1 mmST segment elevation of 1 mm ST segment depression – NSTEMI vs ST segment depression – NSTEMI vs

reciprocal changesreciprocal changes T wave inversions – initial presentation T wave inversions – initial presentation

or evolving infarctor evolving infarct Q waves – may emerge in the initial Q waves – may emerge in the initial

hour, but usually develop at 8-12 hour, but usually develop at 8-12 hourshours

Normal ECGNormal ECG

Injury Patterns on the ECGInjury Patterns on the ECGAnterior wall MI: Anterior wall MI: ST segment elevation V1-ST segment elevation V1-

V4V4

Vessel: LADVessel: LAD

Injury Patterns on the ECGInjury Patterns on the ECG

Injury Patterns on the ECGInjury Patterns on the ECGLateral Wall MI: I, aVL, V5, V6Lateral Wall MI: I, aVL, V5, V6

Vessel: variable perfusion of LAD, RCA, Vessel: variable perfusion of LAD, RCA, LCxLCx

Injury Patterns on the ECGInjury Patterns on the ECGAnterolateral with reciprocal changesAnterolateral with reciprocal changes

Vessels: LAD and 1Vessels: LAD and 1stst diagonal branch diagonal branch

Injury Patterns on the ECGInjury Patterns on the ECGInferior wall MI: II, III, aVFInferior wall MI: II, III, aVF

Vessel: 90% RCA, 10% LCxVessel: 90% RCA, 10% LCx

Injury Patterns on the ECGInjury Patterns on the ECGPosterior Wall MI: Posterior Wall MI: V1-V3 depression, tall V1-V3 depression, tall

upright T, tall wide R wave, R/S ratio upright T, tall wide R wave, R/S ratio greater than 1greater than 1

Vessel: RCA, PDA, LCxVessel: RCA, PDA, LCx

Injury Patterns on the ECGInjury Patterns on the ECGInferior Wall MI with Posterior Wall MI: Inferior Wall MI with Posterior Wall MI:

V1-V3 depression, tall upright T, tall wide V1-V3 depression, tall upright T, tall wide R wave, R/S ratio greater than 1R wave, R/S ratio greater than 1

Vessel: RCA, PDA, LCxVessel: RCA, PDA, LCx

Moving on…Moving on…What do you want to order What do you want to order in addition to an ECG for a in addition to an ECG for a patient presenting with patient presenting with chest pain, suspected ACS?chest pain, suspected ACS?

Initial EvaluationInitial Evaluation IV, O2, monitorIV, O2, monitor Focused H&PFocused H&P CBCCBC Chem 7Chem 7 CK-MB, troponin, myoglobinCK-MB, troponin, myoglobin CXRCXR PT/PTTPT/PTT Possible D-dimerPossible D-dimer ? Repeat ECG? Repeat ECG

Treatment in the ED: STEMITreatment in the ED: STEMI Activate the acute MI page and cath labActivate the acute MI page and cath lab ASA 325mg PO – proven to save livesASA 325mg PO – proven to save lives NTG SL and gtt – reduces NTG SL and gtt – reduces

preload>afterload, dilates coronary preload>afterload, dilates coronary arteriesarteries

Heparin 60 U/kg bolus then 16 Heparin 60 U/kg bolus then 16 U/kg/hourU/kg/hour

? Beta Blocker? Beta Blocker

Treatment in the ED: STEMITreatment in the ED: STEMI Morphine – for persistent pain or anxiety to Morphine – for persistent pain or anxiety to

reduce O2 need, weak sympathetic reduce O2 need, weak sympathetic blocker, preload reducer through venous blocker, preload reducer through venous dilationdilation

Glycoprotein IIb/IIIA inhibitors – started in Glycoprotein IIb/IIIA inhibitors – started in the EC or cath lab for those patients the EC or cath lab for those patients undergoing mechanical coronary undergoing mechanical coronary interventionintervention

Plavix – in consultation with the Plavix – in consultation with the cardiologist as it prohibits CABG for 5 dayscardiologist as it prohibits CABG for 5 days

Treatment in the ED: STEMITreatment in the ED: STEMIReperfusion TherapyReperfusion Therapy

PCI – 90 minute rulePCI – 90 minute rule Most people are eligibleMost people are eligible Decreased risk of bleeding and strokeDecreased risk of bleeding and stroke Higher initial reperfusion ratesHigher initial reperfusion rates Defines coronary vasculature and allows Defines coronary vasculature and allows

for treatment vs. surgical referralfor treatment vs. surgical referral t-PA – when PCI cannot be achieved in t-PA – when PCI cannot be achieved in

90 minutes or is not available90 minutes or is not available 0-12 hours after symptom onset0-12 hours after symptom onset

NTG NTG When to think twice?When to think twice?

NTG: Be cautious…NTG: Be cautious…

BradycardiaBradycardia HypotensionHypotension Inferior or posterior wall MI with RV Inferior or posterior wall MI with RV

INFARCTINFARCT Decreased preload will cause sudden Decreased preload will cause sudden

hypotension and increase infarct sizehypotension and increase infarct size These patients need fluids to increase preload These patients need fluids to increase preload

and help fill the malfunctioning/weakened and help fill the malfunctioning/weakened ventricleventricle

Treatment in the ED: Treatment in the ED: USA/NSTEMIUSA/NSTEMI

Basically the same, but without the Basically the same, but without the cath lab or fibrinolyticscath lab or fibrinolytics

IV, O2, monitorIV, O2, monitor ASA, heparin, NTG, ? beta blocker, ASA, heparin, NTG, ? beta blocker,

morphinemorphine Plavix and GIIb/IIIa inhibitors Plavix and GIIb/IIIa inhibitors

potentially after discussion with potentially after discussion with cardiologycardiology

Admit to a monitored unitAdmit to a monitored unit

Chest Pain: low risk, but risky Chest Pain: low risk, but risky enoughenough

Patients who are low risk with risk Patients who are low risk with risk factors (silly isn’t it?), chest pain free, factors (silly isn’t it?), chest pain free, and have a normal ECG and enzymesand have a normal ECG and enzymes

Observation unit for serial cardiac Observation unit for serial cardiac enzymes and ECGenzymes and ECG

Stress test vs. CTAStress test vs. CTA Cardiology consult variableCardiology consult variable


38 y/o female presents with sudden 38 y/o female presents with sudden onset of chest pain and shortness of onset of chest pain and shortness of breath after retrieving her bags at breath after retrieving her bags at the baggage claim from a flight home the baggage claim from a flight home from Hawaii. She states that it is from Hawaii. She states that it is worse when she takes a deep breath. worse when she takes a deep breath. She also complains of this aching She also complains of this aching pain in her right leg when walking.pain in her right leg when walking.

Chest Pain: What is it?Chest Pain: What is it?80 y/o bedridden patient sent from the NH with 80 y/o bedridden patient sent from the NH with

mental status changes and hemoptysis. She mental status changes and hemoptysis. She is pleasant during the conversation, but has is pleasant during the conversation, but has no idea why she is here. She is actively no idea why she is here. She is actively coughing and appears to have increased work coughing and appears to have increased work of breathing.of breathing.

PMHx: positive for almost everything (she is 80)PMHx: positive for almost everything (she is 80)

Vitals: HR 110, BP 90/60, RR 28, sPO2 88% RAVitals: HR 110, BP 90/60, RR 28, sPO2 88% RA

Lungs: bibasilar rales with right mid lung rhonchiLungs: bibasilar rales with right mid lung rhonchi

Pulmonary Embolism – 2006 Pulmonary Embolism – 2006 StatsStats

Approximately 1 in every 500-1000 Approximately 1 in every 500-1000 EC patients has a PEEC patients has a PE

EM MDs correctly diagnose about EM MDs correctly diagnose about 50%50%

10% of EC patients with PE die within 10% of EC patients with PE die within 30 days even when PE is promptly 30 days even when PE is promptly diagnosed and treateddiagnosed and treated

PE – Risk FactorsPE – Risk Factors

CarcinomaCarcinoma ImmobilityImmobility Trauma or surgery in the last 4 weeksTrauma or surgery in the last 4 weeks SmokingSmoking Estrogen/OCPEstrogen/OCP Pregnancy/PPPregnancy/PP ThrombophiliaThrombophilia Connective Tissue DzConnective Tissue Dz Prior PE or DVTPrior PE or DVT

PE – Signs and SymptomsPE – Signs and Symptoms

Chest PainChest Pain DyspneaDyspnea HemoptysisHemoptysis SplintingSplinting SyncopeSyncope HR > 100HR > 100 Pulse ox < 95%Pulse ox < 95% Unilateral arm or leg swellingUnilateral arm or leg swelling

PE – DiagnosisPE – Diagnosis Basic Labs – CBC and Chem 7Basic Labs – CBC and Chem 7 ? Labs – CK-MB, troponin, PT/PTT? Labs – CK-MB, troponin, PT/PTT D-dimer – low risk patients only with low D-dimer – low risk patients only with low

pretest probabilitypretest probability CXR CXR

Exclude other diagnosis – CHF, PNA, PTXExclude other diagnosis – CHF, PNA, PTX Unilateral basilar atelectasis increases the Unilateral basilar atelectasis increases the

probability of PEprobability of PE Hamptom’s hump – wedge shaped infarctionHamptom’s hump – wedge shaped infarction Westermark’s sign – unilateral lung oligemiaWestermark’s sign – unilateral lung oligemia

PE – Hampton’s HumpPE – Hampton’s Hump

PE – Westermark’s SignPE – Westermark’s Sign

PE – DiagnosisPE – Diagnosis ECGECG

Again to exclude other diagnosisAgain to exclude other diagnosis Most common finding is sinus tachycardiaMost common finding is sinus tachycardia T wave inversions V1-V4T wave inversions V1-V4 McGinn-White Pattern – S1Q3T3McGinn-White Pattern – S1Q3T3 New incomplete or complete RBBBNew incomplete or complete RBBB

Chest CT – moderate to high risk Chest CT – moderate to high risk patients or pre-test probability, patients or pre-test probability, positive D-dimerpositive D-dimer

PE – ECGPE – ECG

PE – ECGPE – ECG

PE – TreatmentPE – Treatment HHeparin unfractionated 80 U/kg bolus eparin unfractionated 80 U/kg bolus

then 18 U/kg/hrthen 18 U/kg/hr LMWH 1 mg/kg SQ q12 hoursLMWH 1 mg/kg SQ q12 hours Coumadin – usually started on the Coumadin – usually started on the

floorfloor

PE – TreatmentPE – Treatment

IVC filter – for pts who failed IVC filter – for pts who failed anticoagulation or have contraindicationsanticoagulation or have contraindications

Thrombolytics – consider in high risk pts Thrombolytics – consider in high risk pts such as systolic hypotension, persistent such as systolic hypotension, persistent hypoxemia, elevated troponin or BNP hypoxemia, elevated troponin or BNP (early shock or shock)(early shock or shock)

Surgery – large clot burden, refractory Surgery – large clot burden, refractory hypotension, floating emboli in the R hypotension, floating emboli in the R heartheart


18 y/o tall, thin healthy male c/o sudden 18 y/o tall, thin healthy male c/o sudden onset L sided CP with shortness of onset L sided CP with shortness of breath. The pain started while he was breath. The pain started while he was inhaling on a marijuana cigarette. It inhaling on a marijuana cigarette. It hurts more to breathe.hurts more to breathe.

Vitals: HR 110, RR 28, BP 110/70, sPO2 Vitals: HR 110, RR 28, BP 110/70, sPO2 96%96%


60 y/o male with a history of severe COPD 60 y/o male with a history of severe COPD c/o increasing shortness of today that is c/o increasing shortness of today that is not relieved with his home inhalers.not relieved with his home inhalers.

Vitals: HR 110, RR 28, BP 110/70, sPO2 90%Vitals: HR 110, RR 28, BP 110/70, sPO2 90%

Heart: distant, tachycardic and regularHeart: distant, tachycardic and regularLungs: diffuse wheezing, decreased breath Lungs: diffuse wheezing, decreased breath

sounds on the rightsounds on the right

PneumothoraxPneumothorax Primary Spontaneous – occurs in Primary Spontaneous – occurs in

people without clinically apparent lung people without clinically apparent lung diseasedisease More common in menMore common in men Associated factors = tall, smoking, Associated factors = tall, smoking,

changes in ambient atmospheric pressure, changes in ambient atmospheric pressure, genetics, MVP, Marfan’s syndromegenetics, MVP, Marfan’s syndrome

Disruption of the alveolar-pleural barrier is Disruption of the alveolar-pleural barrier is thought to occur when a bleb or bulla thought to occur when a bleb or bulla ruptures into the pleural spaceruptures into the pleural space

PneumothoraxPneumothorax Secondary Spontaneous – occur with Secondary Spontaneous – occur with

known underlying pulmonary diseaseknown underlying pulmonary disease More common in menMore common in men Associated with any underlying Associated with any underlying

pulmonary disease including infection, pulmonary disease including infection, ILD, neoplasms, COPD, asthma, etc…ILD, neoplasms, COPD, asthma, etc…

Weakening of the alveolar-pleural barrier Weakening of the alveolar-pleural barrier occurs secondary to the underlying lung occurs secondary to the underlying lung disease either from inflammation or disease either from inflammation or development of bullaedevelopment of bullae

PneumothoraxPneumothorax

IatrogenicIatrogenic Complication of intubation or aggressive Complication of intubation or aggressive

BVM, central line placement, or any BVM, central line placement, or any endoscopic procedure involving the endoscopic procedure involving the trachea or esophagustrachea or esophagus

Consider in any stable patient with Consider in any stable patient with acute deterioration, hypoxia, or acute deterioration, hypoxia, or increased difficulty with ventilationincreased difficulty with ventilation

Tension PneumothoraxTension Pneumothorax

Positive intrapleural pressure causes Positive intrapleural pressure causes compression of the mediastinum and compression of the mediastinum and the contralateral lungthe contralateral lung

Pressure exceeding 15 to 20 mm Hg Pressure exceeding 15 to 20 mm Hg impairs venous return to the heartimpairs venous return to the heart

Leads to cardiovascular collapse if Leads to cardiovascular collapse if not treated immediately not treated immediately this is a this is a clinical diagnosis not a radiographic clinical diagnosis not a radiographic one!one!

Pneumothorax – SymptomsPneumothorax – Symptoms

Ipsilateral sharp CPIpsilateral sharp CP DyspneaDyspnea Pleuritic painPleuritic pain CoughCough

Pneumothorax – SignsPneumothorax – Signs

Sinus tachycardiaSinus tachycardia HyperresonanceHyperresonance Decreased breath soundsDecreased breath sounds Unilateral enlargement of the Unilateral enlargement of the

hemithoraxhemithorax SplintingSplinting HypoxiaHypoxia

Pneumothorax: DiagnosisPneumothorax: Diagnosis

Clinically for tension PTXClinically for tension PTX CXRCXR

Radiolucent band devoid of lung markingsRadiolucent band devoid of lung markings Inspiratory/expiratory viewsInspiratory/expiratory views Lateral decubitus views in sick patientsLateral decubitus views in sick patients Supine CXR may have deep sulcus signSupine CXR may have deep sulcus sign

Thoracic ultrasoundThoracic ultrasound Chest CTChest CT

Pneumothorax - TensionPneumothorax - Tension

Pneumothorax – Deep Sulcus Pneumothorax – Deep Sulcus SignSign

Pneumothorax: Pneumothorax: ManagementManagement

Tension – needle decompressionTension – needle decompression Tube thoracostomy Tube thoracostomy 20-28 F for air, 20-28 F for air,

32F at least if fluid is present32F at least if fluid is present Observation – for PTX < 20% collapseObservation – for PTX < 20% collapse

Reabsorption RateReabsorption Rate 1-2% per day1-2% per day 4-8% if on 100% NRB4-8% if on 100% NRB


60 y/o male complains of sudden onset 60 y/o male complains of sudden onset tearing chest pain that went up into his tearing chest pain that went up into his jaw, through to his back, and then down jaw, through to his back, and then down into his abdomen. He also vomited once, into his abdomen. He also vomited once, is diaphoretic, and appears very anxious.is diaphoretic, and appears very anxious.

Vitals: BP 190/120, HR 110, RR 22, sPO2 Vitals: BP 190/120, HR 110, RR 22, sPO2 95%95%

Aortic DissectionAortic Dissection Occurs more often in men older than 40Occurs more often in men older than 40 HTN is the most common risk factorHTN is the most common risk factor Associated with cardiac surgery, bicuspid Associated with cardiac surgery, bicuspid

aortic valve, stimulant use, and traumaaortic valve, stimulant use, and trauma Age<40, associated with congenital Age<40, associated with congenital

heart disease, Marfan, Ehlers-Danlos, heart disease, Marfan, Ehlers-Danlos, and giant cell arteritisand giant cell arteritis

44% of pts with Marfan’s will develop an 44% of pts with Marfan’s will develop an aortic dissectionaortic dissection

Aortic DissectionAortic Dissection

Type A – 62%Type A – 62% Involve the Involve the

ascending aorta ascending aorta more lethalmore lethal

Type B – 38%Type B – 38% Do not involve the Do not involve the

ascending aortaascending aorta Pt more likely to be Pt more likely to be

older, smoke, have older, smoke, have chronic lung chronic lung disease, HTN, or disease, HTN, or atherosclerosisatherosclerosis

Aortic Dissection - DiagnosisAortic Dissection - Diagnosis

Labs – CBC, chem7, PT/PTT, type & Labs – CBC, chem7, PT/PTT, type & cross, CK-MB, troponincross, CK-MB, troponin

ECG – exclude other dx, 15% may have ECG – exclude other dx, 15% may have ischemic changes ischemic changes 3% dissect back 3% dissect back and most commonly involve the RCA, and most commonly involve the RCA, may have LVH or nonspecific ST or T may have LVH or nonspecific ST or T wave changeswave changes

CXR – abnormal in 80% but nonspecific CXR – abnormal in 80% but nonspecific findingsfindings

Aortic Dissection - DiagnosisAortic Dissection - Diagnosis

CT scan – test of choiceCT scan – test of choice TEE – limited by availability and TEE – limited by availability and

operatoroperator Aortography – no longer the test of Aortography – no longer the test of

choicechoice MRI – excellent test but limited by MRI – excellent test but limited by

availability and instability of the availability and instability of the patientpatient

Aortic Dissection - Aortic Dissection - ManagementManagement

Opioids – decrease pain and Opioids – decrease pain and sympathetic tonesympathetic tone

Beta blockers – esmolol and labetalolBeta blockers – esmolol and labetalol Decrease BP and HR to decrease shearing Decrease BP and HR to decrease shearing

forces forces Should be started first unless the pt is Should be started first unless the pt is

bradycardicbradycardic Nipride – vasodilator, used in Nipride – vasodilator, used in

conjunction with a beta blocker to conjunction with a beta blocker to maintain SBP 100-120maintain SBP 100-120

Aortic Dissection - Aortic Dissection - ManagementManagement

Hypotensive pts – measure BP in all 4 Hypotensive pts – measure BP in all 4 extremities to make sure it is real, extremities to make sure it is real, IVF, blood, immediately to ORIVF, blood, immediately to OR

Type A Type A OR (27% mortality if OR (27% mortality if treated surgically vs. 56% if treated treated surgically vs. 56% if treated medically)medically)

Type B uncomplicated – 10% Type B uncomplicated – 10% mortality when treated medically mortality when treated medically (32% mortality if complicated)(32% mortality if complicated)

Chest Pain – What is it?Chest Pain – What is it?22 y/o healthy male complains of chest and 22 y/o healthy male complains of chest and

back pain after forcing himself to vomit. back pain after forcing himself to vomit. He states he had food stuck in his chest He states he had food stuck in his chest while eating at Mongolian BBQ and then while eating at Mongolian BBQ and then forced himself to vomit for relief. He now forced himself to vomit for relief. He now says that his voice is hoarse, it hurts to says that his voice is hoarse, it hurts to breathe deep, and he is still very breathe deep, and he is still very nauseated. He tried to drink some water, nauseated. He tried to drink some water, but this only intensified the pain.but this only intensified the pain.

Vitals: HR 120 BP, 130/90, RR 25, sPO2 97%Vitals: HR 120 BP, 130/90, RR 25, sPO2 97%

Esophageal Rupture – Esophageal Rupture – Boerhaave’sBoerhaave’s

15% are spontaneous with the 15% are spontaneous with the remainder being iatrogenic from remainder being iatrogenic from endoscopy, NGT, ETT, combitube, endoscopy, NGT, ETT, combitube, foreign body…foreign body…

90% of spontaneous ruptures occur in 90% of spontaneous ruptures occur in the distal esophagusthe distal esophagus

DX – CXR, gastrograffin swallow, CTDX – CXR, gastrograffin swallow, CT ManagementManagement

IV antibioticsIV antibiotics NPO and likely NGTNPO and likely NGT Surgery consultSurgery consult

Chest Pain: What is it?Chest Pain: What is it?26 y/o male c/o retrosternal, sharp CP, difficulty 26 y/o male c/o retrosternal, sharp CP, difficulty

breathing, pain when breathing deeply, and breathing, pain when breathing deeply, and worsening dyspnea tonight when he laid down to worsening dyspnea tonight when he laid down to sleep. He states that for the last week he has had sleep. He states that for the last week he has had URI symptoms and low grade fever, but now feels URI symptoms and low grade fever, but now feels that it has moved into his chest with the increasing that it has moved into his chest with the increasing pain and difficulty breathing.pain and difficulty breathing.

Vitals: HR 110, BP 110/80, RR 24, sPO2 98%Vitals: HR 110, BP 110/80, RR 24, sPO2 98%

Heart: Tachycardic and regular, (+) pericardial rubHeart: Tachycardic and regular, (+) pericardial rubLungs: CTALungs: CTA

Bedside TTE is negative for effusionBedside TTE is negative for effusion

PericarditisPericarditis

PericarditisPericarditis Causes – infectious, injury/trauma, Causes – infectious, injury/trauma,

metabolic, systemic (RA), carcinoma, or metabolic, systemic (RA), carcinoma, or aortic dissectionaortic dissection

DX – clinical suspicion, ECG, echoDX – clinical suspicion, ECG, echo Echo – pericardial effusion and Echo – pericardial effusion and

tamponade are worrisome complications tamponade are worrisome complications pts should be put in obs or pts should be put in obs or hospitalizedhospitalized

Treatment – NSAIDS, steroids for pts Treatment – NSAIDS, steroids for pts who cannot tolerate NSAIDSwho cannot tolerate NSAIDS

THE END!THE END!

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Chest Pain William Beaumont Hospital Department of Emergency Medicine Shanna Jones, MD