chest pain emergencies
TRANSCRIPT
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%
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
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%
Clinical Clues
AMI – angina, exercise tolerance, family history, pain type, clutching chest, CV risk factors
Pneumonia – infective features, immunosuppression, sick contacts
PE – risk factors
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%
Clinical Clues
PE – risk factors
Pericarditis +/- effusion – pain pattern, exam findings
Pneumothorax – clinical findings
Bony metastasis – exam findings, malignancy history
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