Chest Pain EmergenciesEMET 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

Usually 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, 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

Initial Tests

ECG

CXR

Diagnostic Tests

AMI – ECG, biomarkers

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, HR 110, 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, biomarkers

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, HR 100, RR 22, SaO2 95%

Red flags

Syncope

Malignancy

Differential diagnoses

PE

Pericarditis +/- effusion

Pneumothorax

Bony metastasis

Clinical Clues

PE – risk factors

Pericarditis +/- effusion – pain pattern, exam findings

Pneumothorax – clinical findings

Bony metastasis – exam findings, malignancy history

Initial Tests

ECG

CXR

Blood gas

Diagnostic Tests

PE – CTPA, V/Q, echo

Pericarditis +/- effusion – echo, CT

Pneumotharox – CXR, U/S, CT

Bony metastasis – CXR, CT, bone scan

Temporising Treatment

PE – analgesia, oxygen therapy, IV fluids

Pericarditis +/- effusion – analgesia, IV fluids

Pneumothorax – urgency dependent

Bony metastasis – analgesia

Definitive Management

PE – anticoagulation, thrombolysis, embolectomy

Pericarditis +/- effusion – drainage, window

Pneumothorax – spectrum of nothing to drainage

Bony metastasis – XRTx, bisphosphonates