Chest Pain: It’s Not Just For Heart Attacks Anymore Jeffrey L. Jarvis, MD, MS, EMT-P

What is a Differential Diagnosis and Why Should I Form One?

The Big 6 1. MI

2. PE

3. Aortic Dissection

4. Pneumothorax

5. Tamponade

6. Esophageal Rupture (Boerhaave’s Syndrome)

The Little 6 1. Pericarditis

2. Pneumonia

3. Pleurisy

4. Abdominal: Pancreatitis/Cholecystitis

5. Musculoskeletal

6. Herpes Zoster

Case 1 Dispatched: Car vs Deer.

45 HF found in car at HEB, anxious, hyperventilating. No collision. No deer.

HPI: Chest pressure radiating to right arm. SOB, tingling in hands, lips.

VS: BP 120/100, HR 97, RR 34, SaO2 97%, EtCO2 15

VF arrest at arrival to ED.

ROSC, hypothermia, emergent to cath lab

100% LAD, stented.

Discharged neurologically intact. Doing well.

Typical ‘Cardiac Pain’ Pain in chest or left arm (LR 2.7)

Chest pain most important symptom (2.0)

Radiation to:

Nausea/Vomiting (1.9)

Right Shoulder (2.9)

Diaphoresis (2.0)

Left arm (2.3)

S3 (3.2)

Both arms (7.1)

Hypotension (3.1)

Panju, A. JAMA October 14, 1998.

‘Atypical’ Pain Pleuritic pain (LR 0.2)

Sharp/Stabbing (0.3)

Positional (0.3)

Reproducible (0.2-0.4)

Normal ECG (0.1-0.3)

Panju, A. JAMA October 14, 1998.

‘Atypical’ Pain Mild aching - 13%

Sharp/Stabbing - 20%

Burning/Indigestion - 20%

Relief with antacids - 15% (some relief), 7% (complete relief)

Pleuritic/Positional - 16%

Reproducible w/ palpation - 15%

Case 2 45 y/o healthy male being transported to rehab following extended hospital stay with multiple orthopedic surgies after a high speed MVC.

During transport, sudden onset of sharp, left sided chest pain. Worse with inspiration.

VS: BP 145/78. HR 115. RR 24. SaO2 95% on RA

PE: Clear lungs, both legs in post-surgical dressings.

Case 2

Pulmonary Embolism Sudden onset

Tachycardia

Pleuritic chest pain

Hypoxia

Hemoptysis

Hypotension

Cough

Presence of Risk Factors

Dyspnea

Pulmonary Embolism

S1, Q3, T3 S in I

q in III

Inverted T in III

PERC Age < 50

HR < 100

SaO2 on Room Air > 94%

No h/o DVT/PE

No recent Trauma/Surgery

No hemoptysis

No hormone use

No unilateral leg swelling

Case 3 56 y/o male smoker with poorly controlled HTN c/o sudden onset substernal ‘tearing’ sensation radiating to his back.

VS: BP 195/104, HR 110, RR 20, SaO2 95% RA

PE: AOX3, obvious distress, diaphoretic. BP same in both arms.

Dense right sided arm and leg weakness

Case 3

Thoracic Aortic Dissection A man... was seized with a pain of the right arm and soon after of the left... He was ordered to think seriously and piously of his departure from this mortal life, which was very near at hand and inevitable. - J.B. Morgagni, 1761

! There is no disease more conducive to clinical humility than aneurysm of the aorta. - Sir William Osler, 1900

Thoracic Aortic Dissection

Aortic Dissection HTN history (LR+ 1.6/LR- 0.5)

Sudden onset pain (LR+ 1.6/LR- 0.3)

Tearing/Ripping (LR+ 10.8/LR- 0.4)

Migrating (LR+ 7.6/LR- 0.6)

Focal Neuro Deficit (LR+ 33.0/LR- 0.9)

Pulse Deficit (LR+ 5.7/LR- 0.7)

Case 4 56 y/o male with sudden onset anterior chest pain that is pleuritic, sharp and non-radiating. Associated with dsypnea and lightheadedness. History of port placement this morning for chemotherapy.

VS: BP 90/45, HR 124, RR 28, SaO2 88%

PE: Obvious distress. Diaphoretic. JVD. Decreased BS globaly but R>L

Pneumothorax

Pneumothorax Sudden onset

Pleuritic chest pain

Dyspnea

Cough

Tachycardia

Hypotension

Case 5 • 64 y/o male 5 days s/p discharge from CABG has squeezing substernal chest pressure, non-radiating, and progressive dyspnea over the past hour. He is now altered.

• VS: BP 86/50, HR 113, RR 20, SaO2 96%

• PE: Confused, diaphoretic. Healing incisions. Obese. No BS or HS audible b/c of body habitus.

Pericardial Tamponade

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Pericardial Tamponade

Pericardial Tamponade Acute decompensation

May have chronic findings

Dyspnea

Pleuritic chest pain

Exaggerated pulsus paradoxus

Hypotension/ Tachycardia

Increased JVP w/ Inspiration

?Heart tones?

Tamponade

Electrical Alternans

Pulsus Paradoxus

Pulsus Paradoxus

Case 6 • 55 y/o alcoholic with severe left sided chest pain and recent forceful, non-bloody vomiting.

• VS: 136/78, HR 120, RR 18, SaO2 96%, T 98

• PE: Alert, diaphoretic, obvious distress. Crackles bilaterally, abdominal rigidity. Crepitus at base of neck.

Esophageal Rupture

Boerhaave’s

Boerhaave’s Syndrome Sudden onset

Severe retrosternal chest pain

Follows forceful retching

May worsen over days

Fever

Subcutaneous emphysema

Case 7 52 y/o male with sharp, pleuritic chest pain. Recent h/o viral URI. Now with worsening pain, DOE and fever.

VS: BP 124/92, HR 104, RR 18, SaO2 97%, T 100.6

PE: Alert, BS CTA. Subtle friction rub. Pain worse with supine position, relieved with sitting upright.

Case 7

Pericarditis Acute to chronic

Retrosternal chest pain

Sharp, pleuritic

Relieved by sitting

Worsened by lying down

H/O recent upper respiratory illness

+/- friction rub

STEMI imitator

Pericarditis PR depression Diffuse, mild ST elevation

Diffuse PR depression

Upward concavity of ST segment

ST elevation

Case 8 78 y/o woman from NH with sharp, severe pleuritic chest pain, productive cough and dyspnea. No other history available due to dementia

VS: BP 108/78, HR 108, RR 24, SaO2 88%, T 102.5

PE: Awake but demented. Obvious distress. BS crackles RUL, otherwise NL.

Pneumonia

Case 10 28 y/o hispanic, overweight female 5 months post-partum c/o constant, right sided chest pain a/w nausea and vomiting. Last meal was 45 min prior to onset of pain.

VS: 140/78, HR 92, RR 16, SaO2 98%

PE: Alert, Oriented. BS CTA. RUQ tenderness

Case 10

Pancreatitis Cholecystitis/ Cholelithiasis

Case 11 29 y/o healthy male with severe, ‘burning’ left sided chest pain. Recent h/o flu-like symptoms. No other complaints.

VS: BP 120/80, HR 93, RR 14, SaO2 99%, T98

PE: Essentially normal except for....

Herpes Zoster

Buzz Word Bingo

Substernal pressure radiating to right arm, worse with exertion.

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ACS

Sharp, pleuritic pain a/w leg swelling in cancer patient who smokes and just had hip surgery. Pulmonary Embolism

Sudden onset of ripping, tearing chest pain radiating to back and moving slowly into abdomen. Oh... and right sided hemiparesis. Thoracic Aortic Dissection Gradual onset sub-sternal pain, fever and hypotension following EtOH binge with prolonged, forceful retching Esophageal Rupture

Sudden onset of sharp, localized left sided pain a/w dyspnea in otherwise healthy but tall/ skinny young marathon runner. Pneumothorax Gradual onset of right sided pleuritic chest pain a/w fever, cough and SOB. Pneumonia

The Big 6 1. MI

2. PE

3. Aortic Dissection

4. Pneumothorax

5. Tamponade

6. Esophageal Rupture (Boerhaave’s Syndrome)

Young healthy male with sudden onset of sharp, localized left sided pain a/w hysterical wailing interposed with “I didn’t do nothing!” that began immediately after the ever-sosweet “CLICK” of hand-cuffs on the patient’s wrists following a DWI arrest.

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