Ep 27 - Intro to EM: The patient with chest pain

Top Five Diagnoses to Rule Out in Patients with Chest Pain

In emergency medicine, our primary objective is to rule out life-threatening conditions first. This principle guides our approach to patients with chest pain. Here are the top five diagnoses to consider:

1. Acute Coronary Syndrome (ACS)
2. Pulmonary Embolism (PE)
3. Pneumothorax
4. Pneumonia
5. Aortic Dissection

These conditions can have overlapping symptoms but differ significantly in their management and prognosis. Let’s explore these further.

Acute Coronary Syndrome (ACS)

When a patient presents with chest pain, ACS is often the first concern. Key symptoms include central crushing chest pain, which may radiate to the arm or neck. While classic presentations are familiar to most, not all patients exhibit textbook symptoms. Factors like age, gender, and comorbidities can alter the clinical picture.

Initial Assessment and ECG Interpretation

Every patient with chest pain should receive an ECG as part of the initial workup. Interpreting ECGs requires a high level of expertise, as subtle changes can indicate significant pathology. In our department, only senior emergency physicians are tasked with reading initial ECGs to minimize the risk of missing critical findings. It's important to assess each ECG independently, even if previous records are available, as baseline abnormalities can obscure new, acute changes.

Troponin Testing

For patients where myocardial ischemia is suspected, a troponin test, particularly high-sensitivity troponin, is essential. This biomarker helps identify myocardial injury, even in cases where the ECG does not show definitive changes. Given the serious implications of missing an ACS diagnosis, a low threshold for testing is prudent. Approximately 10% of patients with a normal ECG may still have significant disease, highlighting the importance of comprehensive evaluation.

Pulmonary Embolism (PE)

Pulmonary embolism is another critical condition to consider, especially in patients presenting with pleuritic chest pain, shortness of breath, or risk factors such as recent immobilization, malignancy, or surgery. The clinical presentation of PE can vary, complicating diagnosis.

Clinical Decision Tools

The Wells score and PERC (Pulmonary Embolism Rule-out Criteria) are valuable tools in assessing the likelihood of PE. For low-risk patients, D-dimer testing can be used to rule out the condition, reducing the need for further imaging. However, for patients deemed at higher risk, CT pulmonary angiography (CTPA) is the gold standard for diagnosis. The decision to pursue imaging should be guided by clinical judgment and, where necessary, discussed with senior colleagues to avoid unnecessary radiation exposure and follow-up testing.

Pneumothorax

Pneumothorax should be considered in both young, otherwise healthy individuals and older patients with underlying lung disease. The hallmark symptom is sudden onset pleuritic chest pain, often accompanied by shortness of breath.

Diagnostic Approach

A chest x-ray is typically sufficient to diagnose pneumothorax. Given the low radiation dose and high diagnostic yield, x-rays should be performed for most patients with suspected pneumothorax. The imaging will not only confirm the presence of air in the pleural space but also help assess the severity and guide management decisions.

Pneumonia

Pneumonia is a common cause of chest pain, often accompanied by fever, cough, and sputum production. It is more common in patients with a history of respiratory disease or immunosuppression.

Identifying Pneumonia

A chest x-ray remains the cornerstone of pneumonia diagnosis. Clinical symptoms, such as productive cough and fever, along with imaging findings of consolidation, help differentiate pneumonia from other causes of chest pain. While not immediately life-threatening in most cases, timely recognition and treatment are crucial to prevent complications.

Aortic Dissection

Aortic dissection is a less common but highly dangerous cause of chest pain. Classic symptoms include severe, tearing pain radiating to the back. It is critical to maintain a high index of suspicion for aortic dissection, especially in patients with risk factors such as hypertension, connective tissue disorders, or a family history of the condition.

Confirmatory Testing

The definitive diagnostic test for aortic dissection is a CTA aortogram. While a chest x-ray can sometimes reveal mediastinal widening, it is not sufficiently sensitive to rule out dissection. Early consultation with cardiothoracic surgery and rapid imaging are key to managing suspected cases.

Communicating with Patients

Once life-threatening causes have been ruled out, patients often seek answers about their symptoms. When the etiology remains unclear, it’s important to communicate transparently with the patient. Possible benign causes include musculoskeletal pain or gastroesophageal reflux disease (GERD). While it’s reassuring to exclude serious conditions, acknowledging the limitations of our diagnostic tools and advising patients to return if symptoms change is crucial.

Patient Reassurance and Follow-up

Patients should be advised to follow up with their primary care physician for further evaluation and management of non-urgent conditions. Clear communication, including documenting your diagnostic reasoning and plan, is vital for medico-legal protection and patient safety.

Conclusion: Mastering Chest Pain in the ED

Chest pain remains a complex and multifaceted challenge in the emergency department. The ability to swiftly differentiate between benign and life-threatening causes is a critical skill for emergency physicians. Our approach should be guided by a thorough history, physical examination, and appropriate use of diagnostic tools. Remember, the primary goal is to exclude serious conditions, ensuring patient safety while avoiding unnecessary investigations.

As you continue your journey in emergency medicine, refine your skills in evaluating chest pain. Be diligent in your assessments, stay updated with the latest guidelines, and always communicate clearly with your patients and colleagues. This comprehensive approach will not only improve patient outcomes but also enhance your clinical practice.

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