Download Chest pain workup

CHEST PAIN WORKUP
HISTORY
 Pt is a 28 year-old white male who presents to ER following a
small knife wound to the chest sustained in a mugging.
 c/c: “I feel like I’m dying.”
 HPI: Pt arrived in ER with a 1 inch stab wound sustained to
the left side of his chest which doesn’t appear to have
penetrated very deeply. Pt reports he was stabbed with a
knife by a mugger while outside an ATM. Pain is rated 10/10.
Pt has not experienced much in the way of blood loss but he
feels terrible, is breathing rapidly, and is very weak. ER
survey was conducted and Pt was started on IV fluids via 2x
large bore IVs.
HISTORY, CONTINUED
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PMH: None.
PSH: Rotator cuf f surgery on L shoulder 4 years ago.
All: NKDA.
Meds: Fish oil supplements.
Fam: Father (HLD).
Soc: No Tob, 5-7 drinks EtOH/wk, no illicit drug usage.
ROS: +Chest pain, +SOB, +cough; no hemoptysis, no
abdominal pain, no nausea, no vomiting, no diarrhea, no
constipation, no blood in stool, no pain on urination.
PHYSICAL
 VS (abn only): RR 21 , HR 115, BP 58/78 on admit (improving
with free-flow fluids and currently at 74/97).
 HEENT: WNL.
 Neck: Evident JVD (increasing on inspiration), no carotid
bruits.
 Chest: No tenderness, breath sounds clear and equal bilat.
 Heart: Distant heart sounds, tachycardia, normal rhythm,
normal S1/S2.
 Abd: Soft, non-distended, non-tender, BS+.
 Extr: No edema, peripheral pulses weak and symmetric.
ANY INITIAL
DIFFERENTIALS SO FAR?
*Note: while there are obvious aspects of a trauma or
shock work -up with this Pt, what I want you to focus on
is the underlying clinical pathology you think is present.
That is to say, what’s causing this?
DIFFERENTIAL DIAGNOSES
 Ccommon causes of chest pain include:
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Aortic dissection
Cardiac tamponade
Massive hemothorax
Pleural effusion
Pneumothorax
Pulmonary embolism
SO, WHICH INITIAL
IMAGING/LABS SHOULD WE
GET?
INITIAL IMAGING/LABS
 By far the most impor tant imaging/labs in this work -up are:
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ECG
Echocardiography
CXR
CBC/electrolytes
ABG
Continue monitoring VS
 This is not to say you couldn’t order additional tests/labs; however,
these imaging/labs will:
 Cover the differentials in our chest pain work -up
 Focus on the most serious (i.e. life-threatening) targets in our chest pain work -up
(the ones which clinically you cannot afford to miss)
 Help to conserve costs (typically, both our Pt and our attending will not be happy
if we order every test under the sun)
 *As an aside, obviously in any instance where there has been a stabbing, etc.
which arrives, police should be notified
IMAGING/LAB RESULTS
CXR RESULT
 Take a quick precursory
glance to see if there’s
anything abnormal:
 Are the lungs full (i.e. not
collapsed) and clear of
blood/fluid?
 Is there any mediastinal
shift or widening?
 How about the size of the
heart? (Normal is <1/2
chest width)
 What we’re looking for
generally is to be able to
rule out some of our
differentials
CXR RESULT, CONTINUED
 This CXR is clearly
abnormal:
 Lungs are largely obscured
by the heart but there does
not appear to be either a
pneumothorax or pleural
effusion.
 There is no mediastinal
shift (i.e. no tension
pneumothorax) or widening
(no aortic dissection).
 Outline of the heart is
hugely enlarged and
globular in shape. There is
obviously some kind of
effusion present here.
ECHO RESULTS
 Echo shows ventricular
diastolic collapse
ECG RESULTS
 So what does our Pt’s ECG indicate?
 First look at leads II and V5
 Does this look like a normal ECG tracing?
 Next, note the changes in anterolateral leads V3-V6
ECG RESULTS, CONTINUED
 Looks like we have notable QRS alternans (alternation of
QRS amplitude)
 Look at leads II and V5 – see how the QRS height fluctuates?
 Hint: QRS alternans is typical of the problem we’re dealing with
DIFFERENTIAL DIAGNOSES, REVISITED
 So, whittling down our differentials, we have:
 Aortic dissection
 No mediastinal widening, no ripping/tearing chest pain radiating to back.
 Cardiac tamponade
 Triad of hypotension, muffled heart sounds, and JVD (especially increased JVD
on inspiration), in addition to ventricular diastolic collapse on Echo and CXR
showing a massive globular-shaped heart (due to blood in the pericardium).
 Massive hemothorax
 There is definitely blood here, but it appears to be confined to the area around
the heart.
 Pleural effusion
 No apparent blood in the lungs.
 Pneumothorax
 No air in chest cavity, no mediastinal shift.
 Pulmonary embolism
 SOB; however, no fever, no DVT risk, 0/3 on Virchow’s Triad (no
hypercoagulable state, no endothelial damage, and no stasis).
SO WHAT’S OUR
FINAL DIAGNOSIS?
FINAL DIAGNOSIS
 What we’re dealing with here is cardiac tamponade.
 How do we know this? Primarily due to the following triad:
 Muffled heart sounds
 JVD (and Kussmaul’s sign – increased JVD with inspiration), and
 Hypotension
 Along with:
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Tachycardia
Narrow pulse pressure
Ventricular diastolic collapse on Echo
Enlarged, globular heart on CXR
Pt hx of stab wound to chest
CARDIAC TAMPONADE
 Cardiac tamponade occurs due to an excess amount of fluid in
the pericardial sac which leads to:
 Decreased filling of the heart
 Low stroke volume (and narrow pulse pressure)
 Decreased cardiac output
 Cardiac tamponade is typically due to:
 Pericarditis
 Stab wounds
 Malignancies
 So, how do we treat cardiac tamponade?
CARDIAC TAMPONADE TREATMENT
 Management of cardiac tamponade is a relatively simple
process to remember:
 Hospital admission with continuous cardiac monitoring
 IV fluids to promote volume expansion (increasing CO), and
 Pericardiocentesis (stick a needle into the pericardium and suck out
the excess fluid)
IN SUMMATION
 So, to recap remember a few key things:
 Think cardiac tamponade when you see its tell-tale triad of:
 Muffled heart sounds
 JVD (and Kussmaul’s sign – increased JVD with inspiration), and
 Hypotension
 Also remember cardiac tamponade is a potential occurrence following:
 Pericarditis
 Stab wounds
 Malignancies
 Cardiac tamponade is managed with:
 IV fluids to promote volume expansion, and
 Pericardiocentesis to remove the excess fluid
BIBLIOGRAPHY
 American Heart Association
 Available at: http://circ.ahajournals.org
 Cancer Dundee Quizzes
 Available at: http://cancerdundee.wordpress.com/weekly -quizz/
 Heart Pearls
 Available at: http://www.heartpearls.com