Chest pain

Hi, this is Steve Carroll and you're listening to EM Basic. Today we are going to talk about one of the most common yet possibly serious complaints that we face every day, chest pain. This complaints a myriad of possible causes for it, and we are the front line of medicine as far as diagnosing all these possible serious causes. Just about anyone who shows up to any outpatient office with the chest pain will get referred our way for further work up, so we need to be good at this.

First off, I am obligated to say that this podcast doesn't represent the views or opinions of the Department of Defense, the US Army, or my residency program. With that out of the way, let's start with one of the most broad and vexing topics in emergency medicine chest pain.

So first off, you're gonna pick up the chart, read the triage note, make sure to look at their vital signs and look at the EKG. So for the vast majority of patients, the EKG will already be on the chart. So you wanna ask yourself one question real quick. First of all, is this a STEMI? Um so you want to start looking at their an anatomical locations. You want to look at I like to look at them in certain groups. Let's look at one in AVL, two, three in AVF. V one three V three.

and V four to V six and make sure not to neglect A VR. So let's go over this one more time. So one and AVL is your lateral leads, two and three AVF is your inferior leads, V one to V three is your anterior septal leads, and V four to V six is your lateral leads. So then you want to do uh some sort of uh systematic approach. So I use this Dubens method which is look at their rate. Axis, intervals, and look for signs of ischemia.

Now I'm not gonna go over all these things but you know the big things are You know, what's their rate? Are they in sinus rhythm or not sinus rhythm? They have major access deviation and make sure to address all their important intervals. Their PR, their QRS, their QT intervals are the most important ones.

Next, you want to look for any flip T waves, these can be signs of ischemia. You want to look for any elevations that you may see, these can be signs of infarction, whereas any depressions in your ST segment can be ischemia or infarction opposite of that lead that you're looking at. So after you've interpreted the UKG, you want to look at the computer's interpretation and reconcile it with your own interpretation.

So then you want to go on and l ask for the patient's history. So I'd like the OPQRST mnemonic that I think we've all learned. I'll go over this real quick. So onset is when did the symptoms start? Provocation, so what makes your pain better, if anything? quality, what does it feel like? So if the patient can't describe it, you want to offer them adjectives like sharp, dull, pressure. Um you want to give them a kind of a multiple choice list and s if they can't figure out a word to describe it.

Uh one thing I will say is that people will say, Well it's not pain but it's pressure. Just let them know that you mean the same that pressure is the same thing as pain. So then relieving factors what makes your pain better or worse or rather what makes your pain worse. If anything, uh ask about o over-the-counter in medication use. Severity, so on a one to ten scale, um how bad's your pain? This is to monitor their response to treatment. And time, when did your pain start?

Um often the most important question I think we neglect is what exactly were you doing when your pain started? Were you at rest? You were walking around, were you d ha doing strenuous activity, or did you just get stabbed in the chest? Uh so you want to ask these questions. So the big important questions are also the associated signs or symptoms is do you have nausea, vomiting, diaphoresis, abdominal or back pain, near syncope or syncope? So this really helps guide your differential.

Also ask have you ever had this pain before? If they have a cardiac history, how does this uh pain compare to their last event? You know, how does this compare to your last MI or the last time you had to have stencil? Past history you wanna ask them for history of hypertension, hyperlipidemia, MI or CHF. Um

So uh these risk factors are not really helpful to you, but the cardiologists really want to know them up front. Uh bonus points if you can have a recent discharge summary with a recent echo with an injection fraction because the cardiologists will really like to know this.

You also want to ask them if you ever had a catheterization or a stress test. So usually you tell people, have you ever run out of treadmill or have they ever stuck a needle into your groin? Usually people can remember that. If possible, you want to confirm the results of their catheter stress test with their medical records.

A negative cath may still have a thirty percent clot in their LID that can cause a future thrombosis in MI. However, do not let a recent cath or stress test dissuade you from a workout. Medications. You want to focus on their blood pressure meds, their hyperlipidemia meds, aspirin, plavix, cumin, or the new anticoagulant called Bordaxo. So real quick um you want to go over their EKG, look at the anatomical locations, look for any flip T waves, elevations or depressions.

Um make sure to interpret it on your own but then make sure that you don't m uh you look at the computer's interpretation and reconcile it with your own. Then ask your history things, onset, provocation, quality, relieving, severity, time. That's your OPC. Ask them what they were doing when their pain started, their associated symptoms. Have they ever had this pain before? Their past history focusing on cardiac issues.

Um have they ever had catheterization or stress test? And then their medications focus on their blood pressure meds, aspirin, hyperlipidemia, anticoagulants, things like that.

So let's go on to the differential diagnosis of chest pain. So we can talk all day about the differential diagnosis. However, there are six deadly causes of chest pain that you must at least consider in each patient. So the mnemonic for this is remember you take your pet Mac for a walk. Trust me this works. So the mnemonic is P E T M A C. So this stands for P is for P E. E is for esophageal rupture, T is for tension pneumothorax, M is for MI.

A is for aortic dissection and C is for cardiac tampon. So let's go over that one more time. PET MAC, that's PE, esophageal rupture, tension pneumothorax, MI, aortic dissection, and cardiac tampon. So this does not mean that twenty every twenty year old with chest pain needs a CT of their order for dissection. However, you must at least consider these possibilities in every patient with chest pain.

So let's go on to their physical exam. Um first of all just answer their question answer one question. D what's their volume status? Do they look volume down, do they look volume up, or do you think their U volume is? So this is really important in patients that have CHF as a uh past medical history because you want to see if their volume up or not.

So you want to pay close attention to their heart and lung sounds, you want to make sure they have uh really listen for any murmurs, check to see if they radiate. Um probably the murmur we care about the most is aoric stenosis in the emergency room, so make sure that you check uh to see if the murmur radiates their cur carotids or not. Um

Press on the patient's chest wall to see if you can reproduce their chest pain, but do so with caution. So if this is a young person with chest pain that you think is muscoskeletal, then the fact that it reproduces their pain is a helpful finding.

But if it's a fifty year old diabetic female with a good story for MI, then you may not want to really go there because about twenty percent of patients with a diagnosed MI will have reproducible chest pain. So report this finding on your chart and your attending with caution. Also, don't neglect an abdominal exam and a back exam. You'll be very sheepish if you miss that triple A that is a bounding abdominal pulse because you neglected to palpate their abdomen.

Then you want to check their legs for edema or swelling. Is one calf more swollen than the other suggesting a DVT? So is the edema pitting or non pitting? So pitting edema is compressible, you press it in with your thumb and it stays compressed. This suggests. volume overload and capillar capillary leak. Or is it non pitting edema? This is not compressible. Uh this doesn't form an indentation when you press on it. This suggests generally another cause for edema, such as a uh D V T.

Check pulses, especially to make sure they're symmetric. A pulse deficit can suggest an aortic dissection, although not having a pulse deficit doesn't rule out an aortic dissection. So real quick physical exam, look at their volume status. Uh listen to their heart and lungs, check for any murmurs, especially aoric stenosis.

Check press on the patient's chest wall but realize that a decent portion of people with MI will have reproducible chest pain. Make sure to do an abdominal exam and back to the exam, and then check their legs for edema or swelling. And make sure to check their pulses, uh at their radials and for completeness' sake if their uh dorsalis petis as well.

So let's go on to the workup for chest pain. So here's the bottom line. Every patient with chest pain needs an EKG and chest x-ray. The EKG screens for arrhythmia and coronary artery disease, and the chest x-ray screens for esophageal rupture, pneumothorax, and to a lesser extent aortic dissection. Not everyone needs a massive workup for their chest pain. Everyone does need an EKG and chest x ray, beyond that your workup is guided by their age, their risk factors, and their presentation.

So in the EKG. As far as young person considerations, be careful to make sure that this chest pain isn't a syncope component, because if they have syncope along with their chest pain, this is a much different route, and something we're not really going to be talking about today, but you need to look for different things in their EKG. So as far as general considerations on the patient's EKG, once again you want to immediately evaluate for ST elevation.

If your patient has chest pain and ST elevations of two or more millimeters and two or more contiguous leads, um then they need to go to the cath lab, of course, assuming this isn't a young person with pericarditis that has diffuse ST elevation. But if they have chest pain and dead

two or more millimeters of acidity elevation and two or more contiguous leads, then you need to get them to the cath lab. Your workup's done, it's it's over. They need to go. Yes, they still need a few things before they leave for the cath lab, but uh we'll talk about that a little later.

If you see a left bundle branch pattern that is new or presumed to be new in a patient with chest pain, this is also an indication for the cath lab. However, I'll warn you that this may be changing from an emergent trip to the cath lab to an urgent trip to the cath lab in a few years, but stay tuned. As of right now, if you have a new or presumed new left bundle branch pattern with chest pain, then this is an indication for an immediate catheterization.

Also realize that the left bundle branch block pattern uh makes interpreting for ischemia and infarction much more difficult. If you want more on this, Google Scarbosa's criteria. It's an excellent pimp question in fodder for rounds. That's spelled S G A R B O S S A Scarbosa.

Look hard for ischemic changes. Look for flip T waves or ST elevations or depressions. If something seems abnormal, look to see if the patient has an old EKG to compare it to. If any of the abnormalities are new, this is much more concerning. So let's go on to the chest x ray. So for most of your chest pain roulette mi, this is just a box to check. However, your suspicion of the patient's diagnosis can help you figure out what you're looking for.

So for example, if you have a young thin smoker who's an asthmatic with a sudden onset of chest pain and shortness of breath, Looking for that pneumothorax is important. And that patient who may be fibrile with their chest pain, looking for that pneumonia is important. Or if the patient has crackles and maybe volume overloaded, then it's nice to confirm your suspicion of pulmonary edema by seeing wet lungs on the chest area.

Although chest x ray is a reasonable screen for aortic dissection, it is not a definitive test. Widy the amino style is about sixty or seventy percent sensitive in the diagnosis of dissection, but in a patient with a low pretest probability is a reasonable screen.

For the complaints of esophageal rupture, aortic dissection, and cardiac tamponine, these can often reasonably rule be reasonably ruled out with a good history. Let's address those three diseases quickly. So first esophageal rupture. This is also called Borhov syndrome. On the X ray X ray, look for free air into the diaphragm. Uh do they have peridonitis on their abdominal exam? Do they have a history of recent forceful vomiting? Or did they have a recent endoscopy?

Or are they a big alcoholic? These patients usually look sick as stink, but this is a diagnosis with a high mortality rate so it has to be addressed. Next, aortic dissection. Hypertension is by far the most prevalent risk factor in this disease. After that, other risk factors include pregnancy and connective tissue diseases such as Marfans and Ellers Danlins.

Most classically this is described as ripping or tearing pain in someone's chest that radiates to the back. People talk about unequal BPs between left and right arms, but these are unreliable at best. If present, you are generally looking for a difference of at least twenty millimeters of mercury between the two arms. Anything less than that is not as significant. Furthermore, BP changes are only about sixty to seventy percent sensitive for the disease.

In a young person with chest pain, make sure that they don't appear morphenoid with long, slender fingers and a very thin and tall build, or have signs of Ellers Danlos such as hyperflexible joints. A real periphery aoric dissection is that if you have chest pain plus a motor or neurodeficit,

or you have chest pain and a seemingly unrelated complaint elsewhere in your body, you should consider a dissection since the odor is the only thing that connects both. Let's say that one more time. So you have chest pain plus a motor or neurodeficits, think of dissection. And if you have chest pain and a seemingly unrelated complaint elsewhere in your body, consider a dissection. So the chest test of choice to rule out dissections is CTA order with contrast.

If the patient has a di allergy or has an elevated creatine, which you can get if the dissection takes out the renal arteries, then you'll need to get a transesophageal echo or cardiac MRI to rule out this serious cause of chest pain. Cardiac tamponon So classically this is described as muffled heart sounds, JVD, and hypotension, which is Beck's triad, although these are very late findings and often do not occur altogether.

Classically, the pulse pressure is narrow due to the incomplete emptying of the ventricle and diastole. This can easily be ruled out with a bedside ER ultrasound, but it is often unnecessary. Unless the patient has risk factors like cancer for an emul uh such as a moleign fusion.

Or they have kidney failure on dialysis, they may have a uremic effusion, or unless they are a trauma patient and you think they're traumatic tampon. This is one diagnosis that you don't see a lot compared to everything else on your left. So let's go through those one more time.

Uh three uh causes you can mostly rule out by history is esophageal rupture, Borhoff syndrome. Uh do they have free air on their chest x ray or peritonitis on their abdominal exam? Do they have risk factors such as forceful vomiting? Are they an alcoholic or did they get a recent endoscopy? Aoric dissection, hypertension is the biggest risk factor. Other risk factors include pregnancy and connective tissue disorders.

So this is you classically your ripping or tearing chest pain. Don't rely on unequal BPs or a chest x-ray with a witamine stinum as these are not completely sensitive for the disease. Keep in mind if you have chest pain plus a motor or neurodeficit elsewhere in your body or you have chest pain plus another complaint elsewhere in your body, think of dissection.

Cardiac tampanine, look for some risk factors, you know, for such as cancer or uh kidney uh end stage renal disease or a traumatic tamponine. You can rule it out with an ultrasound at the bedside if you need to.

So let's go back to the workup. So From there we're left with two diagnoses P E and M I, both of which have entire chapters of root in Rosen's intent allies dedicated to them, so I'm not going to be able to summarize them in a short time we have here. I am going to go over the general treatment and disposition parameters for these two diseases quickly, but I'm going to spend more time on these in later episodes.

So let's talk about MI. This disease keeps us in business. It has spawned entire new units to the hospital called chest pain units where we admit low risk people to make absolutely sure that they don't have an MI. So you have to make the decision whether or not you want to pursue this work at the start. An attending of mine wisely once said be liberal with your EKGs but stingy with your enzymes.

In general, anyone can get an EKG, but if you get cardiac enzymes, you are virtually committing the patient to admission because one set of enzymes is not enough to rule out MIRACS. Although I will say that this is being looked at frequently in literature, but however the current standard of care says you in general you can't get away with just one set of enzymes for any patient that you think may have MI or ACS. So you have to put the patient's story together.

Sharp pain is a little less concerning than pressure. Pain that is brought on or made worse by exertion is worrisome. Pain that has persisted for hours is more worrisome than pain that's fleeting. Classically the MI pain is in the left side of the chest and radiates to the left arm and jaw, is brought on at rest or is exertional, and is associated with nausea, vomiting, and diaphoresis.

So the one thing I'll say don't blow off a patient who is sweating. That being said, every EM doctor out there has seen a patient whose chief complaint was ear pain or toe pain who was having a STEMI. So a few cautions in the history. Pain that radiates into the right extremity of your shoulder is less sensitive for cardiac pain, but is very specific. So if someone says their pain radiates to the right side, you should take it very seriously even though it's not the quote unquote classic.

Uh story for M I. Also, women tend to have fewer classic symptoms and may only be fatigued and weak. This goes double for any diabetic. So be very concerned about your female diabetics, they are set up for an atypical presentation. They may just be a little weak and have some fatigue and some nausea, and that's their presentation for MI. They may have no chest pain whatsoever.

So now once you've decided to pursue MI and ACS diagnosis, here's your general workup. So your general workup is the this this cardiac set we like to talk about. So this is an EKG, a portable chest x-ray. And then some labs. So a CBC, Chem Ten, CoAGs, and cardiac enzymes. Let's go through those labs individually, kind of talk about why we get those individual labs. So a C V C we're most interested does the patient have some sort of profound anemia that could be causing their chest pain.

A chemist chem ten is look for electrolyke abnormalities. Uh the cardiologists love to replete everyone to a potassium of four and a magnesium of two, although there's really not a lot of evidence for this, but you want to make sure they don't have a big uh electrolyte abnormality. Coags, these are usually low yield, but if you're going to anticoagulate someone because you're thinking they're having an MI or they're having unstable angina, then um you want a baseline set of coags.

And then cardiac enzymes. So this usually includes a troponin, but most places include a CK, CKMB plus or minus a myoglobin or a BNP. Um so the troponin, just real quick we're gonna review this. Uh troponin um is elevated within the forty s first four to six hours. of MI and stays elevated for three to five days, whereas C K um uh is elevated somewhere in the six to eight hour range and then uh slowly goes down over about one to two days.

So now we've ordered the enzymes and your you and your attending have decided that this person is not a one set rule out candidate, which um we talked about before is you know some attendings may say it's an option, some may not. You have to go with what you're what you're attending things. So every patient who is admitted for a role at MI needs three hundred twenty five of aspirin unless they have a bona fide allergy or contraindication of aspirin.

You also give at you give aspirin to people even if they're on cumidin. If they've taken a full strength aspirin in the past twenty-four hours, you don't need to repeat it. However, they need 325 milligrams of aspirin in the past 24 hours one way or another. So then there's some adjunct. First of all, nitroglycerin, so there are plenty of ways to skin this cat.

I prefer in my institution advocates to start with nitroglycerin zero point four milligrams sublingual every five minutes times three doses. Hold if the patient is chest pain free or their systolic is less than one hundred. Before you give this, you must make sure that your male patients haven't taken any Viagra, Cialis, or Levitra recently.

Viagra or Cialis, you want to ask them if they've taken it in the past twenty four hours. I'm sorry. If for Viagra or Levitra you want to ask them if they take in the past twenty four hours. For Cialis it's the past seventy two hours. Uh if they've taken these medicines recently and you give them nitroid, they're gonna bottom out their blood pressure and it's not gonna be pretty.

Also make sure your the patients have an IV in place before you give nitro because even healthy people can pass out from it. But however if they do this it's usually fluid responsive. Give them a five hundred C C normal saline bolse and they do better. Also, make sure you don't see any signs of posterior MI um such as the mirror sign in V one or anterior depressions because or inferior depressions because they tend to bottom out their um blood pressures with nitro as well.

So after you've given sublinguals uh sublingual, some people will put nitro paste on, especially if it gets the if nitroglycerin gets the patient pain free. However, the teleunits where I work won't accept this. They say it's a titratable drug. I really don't agree, but since my patients can't go upstairs with a nitro patch on, I generally don't do nitro patch. Um if the patient is still having pain after aspirin and nitro, it is unreasonable to try some morphine.

Just make sure to give some zoopharin with it to prevent nausea and vomiting. Unless they are in severe pain and rather on the stretcher, four milligrams of iv morphine with eight milligrams of zofarin tends to work pretty well. My institution has this big thing about going upstairs pain free. Otherwise the nursing uh supervisor makes you put the patient in the cardiac care unit. Your institutions may have similar rules, so you have to follow them.

Feel free to titrate up that morphine as needed, but realize that if you think that the patient still looks bad or is having refractory pain that this may be continuing ischemia. You should get another EKG, look for changes, and consider a nitro drip and admission for unstable anginome. if you're having a hard time getting the patient pain free. This is the whole this is a whole other talk into itself, so I'm not gonna go into the spectrum of acute cornea syndromes now.

The low risk quote unquote rule out ACS patients are by far the bulk of our patients that you admit for chest pain, so that is what I'll continue to talk about. Once you have the patient pain free, repeat an EKG. Even if they never had pain in the ED, get a second EKG to check for changes while they've been here in the emergency room. Compare both EKGs and see if they have any new T wave or S T changes or if any morphologies have changed.

So now it's time to admit. You will be doing this a lot for chest pain, so here's a quick example of how to talk to a cardiologist. In this case, this is a patient for a low risk chest pain rule. You say to the patient hi uh you say to the cardiologist, Hi, this is doctor Turnanburn in the E D. I have a forty year old male with a history of hypertension with no known cardiomy artery disease.

who comes in with three hours of chest pain at home. It started at rest and persisted for three hours. It wasn't exertional or positional. He describes a sharp pain in his chest, five out of ten in severity, no other associated signs or symptoms, Exam is normal, EKG is normal and non ischemic, chest x rays normal and cardiac enzymes are normal as well.

He got a three hundred twenty five milligram aspirin and one sublingual nitrile with total relief as pain. Epeat DKG has no changes. I would like to admit him for a low risk rule out. This sits on everything a cardiology fellow or attending would want to hear about the patient in order to admit them for a low risk ACS rollout.

So let's kind of review this one more time. Um you know, once you've decided that you're gonna work out the patient for uh MI or ACS, you're gonna get your EKG, portable chest x ray, C B C, chemten, coags, and cardiac enzymes. Um every patient needs an aspirin three hundred twenty five milligrams. You can use nitroglycerin, um start with some sublinguals.

Um make sure to get some hold parameters for Systogless than a hundred. Make sure your um male patients did not take in Viagra, Cialis, or Levitra recently, and make sure you don't think that they have a posterior MI. Um once uh if they're still having pain after nitroglycerin, it is unreasonable to try some morphine. Just be careful if you think they're having uh continued pain and refractory pain that they may be having unstable androgen, that's a whole different story.

Um once you get the patient pain free, make sure to repeat an EKG. Even if they never add pain in the emergency room, always make sure to get two EKGs on everyone you're going to admit for chest pain.

And then you want to make sure to talk to a cardiologist, tell them upfront the patient's age and their risk factors, whether they or not they have coronary artery disease, give a brief synopsis of their history Uh make sure to let them know that their EKG, chest x-ray, and cardiac enzymes are normal, that they got an aspirin, maybe if they got any nitro, and then that a repeat AKG is negative, and that you're want to emit them for a low risk.

So let's talk about pulmonary embolism. So classically in pulmonary embolism we talk about this pleuritic chest pain, this is the chest pain all over the chest wall. and uh with associated shortness of breath, tachypnea, tachycardia, and hypoxia. So risk factors include for P E include O C Ps.

Pregnancy, trauma, recent surgery, a suspicion for a DVT and malignancy. Now this doesn't mean that every female on birth control pills with chest pain gets a CT, although there are people that practice this way. One word of caution, without going into too much detail. Let's say that the patient is on cuminant with a therapeutic therapeutic INR, so this is usually between two and three.

So if they're therapeutic on their INR, do they have a less risk of having a P compared to someone who isn't coacclated? The answer unfortunately is no. This has been studied and has been shown that while you will get fewer DVTs and PEs over your lifetime with Cubanin, your overall risk of PE after walking through the door of an E D is no less likely than if you were therapeutically anticoagulated.

This is one study that you may wish had never been done but such as life. Bottom line do not equate a therapeutic INR with protection from PE or DBT. So let's go through the basic work of for P and how to get things done. First of all, you're gonna get your EKG, uh your chest x ray. You may want to get a PA in lateral um if the patient is stable and they can handle going over to the radiology department.

And then as far as labs, C B C, Chemten and Coags, so as far as why you want that C V C it's pretty low yield up for us but the emitting services want it so I think it's pretty reasonable. A chem ten if uh you want another creatinine for a C T uh radiology is gonna require it. And then coags. If you have to anticoagulate the patient, you should have baseline coags on on record before you anticoagulate them.

So here comes the tricky part. This is probably one area in medicine that is the most controversial right now. I will tell you how I approach this and I think this is how most attendings uh approach pulmonary embolisms. I will warn you up front, do not indiscriminately order D dimers on everyone whom you consider P on. If you do, you're going to get lots of unnecessary CTs and expose a lot of patients to radiation unnecessarily.

So first off, the the first question you need to ask yourself is what is your gestalt um for the patient? What what's your gut feeling? Are they low, medium, or high risk probability based on what you think? For example, the female with the tiniest bit of reproducible chest pain who isn't tachycardic probably doesn't have a PE. However, that pregnant patient who's coughing up blood, who's tacky, hypoxic, and tachynic with a swollen right leg is probably pretty high risk.

Medium is somewhere in between and it's a real gray area. You have to consider their overall story and risk factors when deciding whether to go down this diagnostic route, and your attendance will have a better gestalt than you when you first start out. However, is always needs to be however, P E always needs to be on your differential for chest pain.

So why do I make a big deal about your gut feeling? Because it allows us to use a clinical prediction rule to eliminate any further need for testing for pulmonary embolism. Up front though, if your suspicion is moderate or high for pulmonary embolism, you need to get the CT to rule it out. Um the current state of practice is that you'll never be wrong to scan someone who's moderate or high risk without doing D dimer first, although this may be changing in the future.

The vast majority of patients who get PE workups fall into this low risk category, and this is where you can avoid doing a CAT scan by using a clinical decision rule. I like the PERK rule. This stands for PE Ruleout Criteria. Uh you first make the decision that the patient is low risk based on your gut feeling. If they're medium or high risk, stop there and order the CT. So if they're low risk, see if they have any one of these six criteria.

Uh if they have any one of these six criteria, you cannot use this uh decision rule to say that they don't have pulmonary embolism. So the mnemonic for this is breaths B R E A T H S. So the first one is B for blood in the sputum if they have hemoptosis. This is kind of a no duh thing. Of course, you know, they're not low risk for PE if they have hemopsis. R is for rumair sat less than ninety five percent. E is for estrogen or OCP use.

Age is greater than fifty years old and T is for thrombosis in the past, uh PE or DVT, or the fact that you have a current clinical concern for a D V T. H is for heart rate greater than a hundred, so this is the thing that gets us the most because it's heart rate at any time documented at a hundred, whether it's in triage or in the back main emergency room. and S is for surgery in the last four weeks. So let's go over this one more time. Breaths, B is for blood and sputum.

R is for rumor sat, less than ninety five percent, E is for estrogen or OCP use, A is for age greater than fifty years old, T is for thrombosis in the past, APE or DVT, or a current clinical concern for a DVT.

H is for heart rate greater than a hundred and esteris is for surgery in the past four weeks. What I recommend is if you have your little uh peripheral brains, the thing the places you write things down on um is that you write down this decision rule so that you make sure you don't miss anything.

So if they are low risk for PE and they have none of these six criteria, you stop there. You are done. You don't need a D dimer, you don't need any further testing. So their risk of PE is not zero, it's one point eight percent. However, Two percent of people will be harmed by any coagulation that you give them for a pea, so that's why the one point eight percent threshold is important.

Because in this situation you're going to harm more people than you're helping by testing them because two percent of people will be harmed by anchoagation, but their risk is only one point eight percent for pulmonary embolism. Um so if you test people who are perk negative, you're gonna harm more people than you're gonna help in the long run. And I think uh medical legally and uh current state of practice this is an acceptable risk benefit.

However, if the patient is PERC positive, usually it's because they have a heart rate over a hundred or they use OCP so that they can. Then most people will do what we call throw the D dimer dice. This is the only time when you should get a D dimer in a PE workup. It is very sensitive, ninety five percent or greater, but not very specific. It's about forty percent specific.

So this means that if you apply it indiscriminately you're going to give a lot of false positive positives and give a lot of people a lot of unnecessary CTs.

So if your perk positive and the D dimer is negative, then you stop. You and your patient won that dice throw and your patient doesn't need a C T. If the D dimer is positive, then you've made a bad throw of the dice and they get a C T A for P E. This approach has not been backed up by current literature, but I think it's how most clinicians practice.

I think most attendees will be impressed by this current way of thinking on working up pulmonary embolism, so keep this in mind. So a quick word on PE treatment if you diagnose of someone with a PE. For patients with a small PE, this is called submassive, who don't have any vital signs abnormalities, they should get treatment with low knocks at one milligram per kilogram sub Q or heparindra.

If you have diagnosed RPE, you will look like a rock star if you add on cardiac enzymes and a BNP. If your cardiac enzymes or BNP are elevated or you have an echo with RV strain, then this can be an indication for thrombolytics. These treatment recommendations are currently in flux and I want to save that discussion for another time.

If the patient is hemodynamically unstable, usually this is a systolic less than ninety, then this is considered a massive pulmonary animalism and should get thrombolytics right away. So just to review, no vital sign changes, give low vinox or heparin and order the cardiac enzymes or BMP.

If the cardiac enzymes or BMP are elevated, get your consultant on board and talk to them about the need for thrombolytics. If the patient is unstable in the emergency room with a diagnosed PE, then they need thrombolytics right away. So let's go over pulmonary embolism uh workup real quick.

Uh first of all, um, you know, the thing that we talk about for polarism is polyuritic chest pain with shortness of breath, tachycardia, risk factors, OCPs, pregnancy trauma, recent surgery, or the suspicion for a D V T. Um just because they're incuminant or anticoagulated doesn't mean that they couldn't possibly have a pulmonary neumbolism or D V T as well.

So the general workup EKG, chest x ray, CBC, chem ten and coags. The next thing to do is to risk stratify the patient. What's your gut feeling? Are they low risk, medium risk, or high risk? If they're medium or high risk, you should probably just proceed to a CAT scan and get get that out of the way. If they are low risk, then you can use the PERC criteria, uh the breaths criteria to uh determine whether you need to do any more testing.

If they are perk negative, they do not need any further testing. If they are PERC positive and you still have them on a low risk category, then you can do a D dimer to try to avoid the need for a CAT scan. About thirty percent of the time you're gonna uh avoid that need for a CAT scan, but about seventy percent of the time you're gonna end up doing that CAT scan.

Um if you diagnose someone with a pulmonary embolism and they are otherwise fine and they are stable hemodynamically, they can get Lovinox, 1 mg per kilogram sub Q, or a heparin drip. From there you should probably order a set of

of cardiac enzymes and a BMP. If they have an elevation of their cardiac enzymes or a BMP or if they have an echo with R V strain, then this can be an indication for thrombolytics because they're actually straining their heart from the clot burden and from their pulmonary embolism. Um if they are hemodynamically unstable.

they're altered or they have a systolic blood pressure less than ninety, then they should get thrombolytics right away out of the emergency room. So this is how to work up chest pain in the ED in a nutshell. This is just a basic review that has really glossed over the subtleties of chest pain workups and shouldn't be the only source of your learning. What I suggest is to listen to this several times.

Read the summaries that are provided, and print out the summaries or write down the useful nuggets. Carry them around with you on shifts and And use them when you can take care of patients. Better yet, go look up the PROK study and read it for yourself, or read the chapters in Rosen or Tentanales and see how this basic rapid review correlates with what's in the books. Until next time, this is Steve Carroll for the EM Basic Podcast, signing off.