A. 49 DDX Thoracic Pain Flashcards
A. 49 DDX Thoracic Pain
What is thoracic pain
Chest Pain (Thoracic Pain): Non-traumatic chest pain is a prevalent reason for emergency department visits, affecting both inpatients and outpatients. The differential diagnosis (Ddx) is extensive and encompasses cardiac, gastrointestinal, musculoskeletal, and psychiatric causes. It is crucial to evaluate and assess any life-threatening causes of chest pain immediately. Once these have been excluded, a more detailed history and examination should be conducted to refine the diagnosis.
A. 49 DDX Thoracic Pain
Management Thoracic Pain
- ST-Elevation Myocardial Infarction (STEMI):
- Immediate cardiac intervention (e.g., angioplasty).
- Administer antiplatelet agents and statins.
- Continuous monitoring and follow-up tests. - Non-ST-Elevation Myocardial Infarction (NSTEMI):
- Focus on risk stratification.
- Utilize treatment options like medications to manage ischemia and potential coronary interventions. - Other Causes:
- Cardiac Tamponade: Consider fluid removal and monitoring.
- Esophageal Rupture: Requires surgical intervention.
- Pulmonary Embolism: Manage with anticoagulation and potential CT scans for confirmation. - Assessment:
- Perform an ABCDE assessment and acquire ECG.
- Use clinical history, physical exams, and chest X-rays (CXR) to identify alternative diagnoses.
A. 49 DDX Thoracic Pain
Red Flag Symptoms
Sudden Onset: Immediate occurrence of pain.
Exertional Chest Pain: Pain triggered by physical activity.
Unilateral or Left-Sided Pain: Focused on one side, particularly the left.
Radiation: Pain that spreads to the left arm, jaw, or back.
Shortness of Breath: Difficulty breathing associated with the pain.
Quality of Pain: Described as crushing, pressure-like, tearing, or ripping.
New Heart Murmur: Recent development of an abnormal heart sound.
Diaphoresis: Sweating, nausea, or vomiting accompanying the pain.
Chest Wall Crepitus: A crackling sound indicating potential underlying issues.
Distant Heart Sounds: Faint heart sounds upon auscultation.
Systolic Pressure Difference: Variance greater than 20 mm Hg between arms.
Pulsus Paradoxus: Significant drop in blood pressure during inhalation.
Hypotension: Low blood pressure.
Hypoxia: Low levels of oxygen in the blood.
A. 49 DDX Thoracic Pain
STEMI characteristic features
Pain Quality: Heavy, dull, pressure-like, or squeezing sensation.
Location: Substernal pain radiating to the left shoulder.
Associated Symptoms: Nausea, vomiting, diaphoresis, and anxiety.
A. 49 DDX Thoracic Pain
STEMI DX Features
ECG:
- ST-segment elevation or depression
- T-wave inversions
- Presence of Q waves
Troponin: Elevated levels
TTE (Transthoracic Echocardiogram):
- Hypokinesis
- Regional wall motion abnormalities
A. 49 DDX Thoracic Pain
STEMI Characteristic features
Pain Quality: Heavy, dull, pressure-like, or squeezing sensation.
Location: Substernal pain radiating to the left shoulder.
Associated Symptoms: Nausea, vomiting, diaphoresis, and anxiety.
Additional Symptoms: Dizziness, lightheadedness, and syncope.
Relief: Pain may improve with nitroglycerin.
A. 49 DDX Thoracic Pain
STEMI DX
ECG:
- Nonspecific changes, such as T-wave inversions and ST-segment depressions
Troponin: Normal or elevated levels
TTE (Transthoracic Echocardiogram):
- Possible regional wall motion abnormalities
A. 49 DDX Thoracic Pain
Aortic Dissection
Symptoms:
- Sudden onset of severe, sharp, tearing chest or abdominal pain radiating to the back
- Hypertension, syncope, and neurological symptoms
- Asymmetrical blood pressure and pulse deficit
- New diastolic murmur
- Signs of myocardial ischemia
A. 49 DDX Thoracic Pain
Cardiac Tamponade Symptoms:
- Tachypnea and dyspnea
- Tachycardia
- Pulsus paradoxus
- Cardiogenic shock
- Back Pain:
- Hypotension
- Jugular vein distention (JVD)
- Muffled heart sounds
A. 49 DDX Thoracic Pain
Cardiac Tamponade Diagnostic Findings:
- ECG: Low voltage, electrical alternans
- CXR: Enlarged cardiac silhouette
- TTE: Circumferential fluid layer, collapsible chambers, high ejection fraction (EF), and dilated inferior vena cava (IVC)
Movements During Breathing:
- Inspiration: Both ventricular and atrial septa move sharply to the left
- Expiration: Both ventricular and atrial septa move sharply to the right
A. 49 DDX Thoracic Pain
Aortic Dissection Diagnostic Findings
- Elevated D-dimer
- ECG: Nonspecific ST-segment changes
- CXR: Widening of the aorta
- CT Angiography of chest/abdomen: Internal flap with false lumen
- TEE: Proximal aortic dissection, tamponade, aortic regurgitation
A. 49 DDX Thoracic Pain
Pericarditis Symptoms:
- Sharp, pleuritic, retrosternal chest pain
- Worsens when lying down
- Improves when leaning forward
- Not relieved by nitrates
- High-pitched pericardial friction rub
A. 49 DDX Thoracic Pain
Pericarditis Diagnostic Findings:
- Elevated ESR, CRP, and leukocytes
- Increased troponin levels
- ECG: Diffuse ST-segment elevations (not reciprocal), along with PR-segment depression and T-wave inversions
- CXR: Typically normal
- TTE: May reveal pericardial effusion
A. 49 DDX Thoracic Pain
Esophageal Perforation Symptoms:
- Retrosternal chest pain
- Neck pain
- Epigastric pain radiating to the back
- Dyspnea, tachypnea, and tachycardia
- Dysphagia
- Signs of sepsis
A. 49 DDX Thoracic Pain
Esophageal Perforation Diagnostic Findings:
- Mackler’s Triad: Chest pain, vomiting, subcutaneous emphysema
- Mediastinal crepitance
- History of recent endoscopy or severe emesis (Boehmer’s syndrome)
Imaging:
- CXR and upright AXR: May show mediastinal air and/or subdiaphragmatic air, pleural effusion, or pneumothorax
- Lateral neck X-ray: May reveal subcutaneous emphysema
- Contrast esophagography (gold standard): Demonstrates contrast leak
A. 49 DDX Thoracic Pain
GERD and Erosive Esophagitis Symptoms:
- Postprandial substernal chest pain
- Pressure, burning sensation, and reflux symptoms
- Symptoms worsen when lying supine and after consuming certain foods (e.g., tea, coffee, spicy items)
- Epigastric tenderness
A. 49 DDX Thoracic Pain
GERD and Erosive Esophagitis Diagnosis:
- Clinical diagnosis
- Definitive diagnosis requires EGD and 24-hour esophageal pH monitoring
A. 49 DDX Thoracic Pain
Peptic Ulcer Disease Symptoms:
- Epigastric pain:
- Duodenal ulcers: relieved by food; associated with weight gain
- Gastric ulcers: worsened by food; associated with weight loss
- Signs of gastrointestinal bleeding
- History of NSAID use
A. 49 DDX Thoracic Pain
Peptic Ulcer Disease Diagnosis:
- Anemia
- Positive FOBT (fecal occult blood test) in cases of bleeding
- Urea breath test for H. pylori is positive in most cases of PUD
- EGD reveals mucosal erosions and/or ulcers
A. 49 DDX Thoracic Pain
Acute Pancreatitis Symptoms:
- Severe epigastric pain radiating to the back
- Nausea and vomiting
- Epigastric tenderness, guarding, and rigidity
- Upper abdominal pain
- Hypoactive bowel sounds
- History of gallstones or alcohol use
A. 49 DDX Thoracic Pain
Acute Pancreatitis Diagnosis:
- Elevated lipase and amylase levels
- Abdominal ultrasound shows pancreatic edema, peritoneal fluid, and gallstones
- Abdominal CT with IV contrast reveals pancreatic edema, peritoneal fat stranding, and gallstones
A. 49 DDX Thoracic Pain
Pulmonary Embolism
Symptoms:
- Pleuritic chest pain
- Acute onset dyspnea and hypoxemia
- Cough with hemoptysis
- Unilateral leg swelling or history of DVT
- Hypotension or shock (in cases of massive PE)
A. 49 DDX Thoracic Pain
Pulmonary Embolism Diagnosis:
- Elevated D-dimer levels
- Troponin and BNP levels
- ECG: normal sinus rhythm (most common), sinus tachycardia, signs of right ventricular strain
- CT Angiography: shows pulmonary artery filling defect
- V/Q scan: indicates pulmonary ventilation-perfusion mismatch
- Transthoracic echocardiogram (TTE): right ventricle appears normal with adequate apical movement
Wells Criteria for pulmonary embolism
A. 49 DDX Thoracic Pain
Symptoms:
- Severe, sharp chest pain
- Dyspnea and hypoxemia
- History of trauma
- Hyperresonance on percussion, decreased breath sounds, tracheal deviation
- Tachycardia and hypotension
