4. Visceral Pain
Visceral fibers enter the spinal cord at
several levels leading to poorly localized,
poorly characterized pain. (discomfort,
heaviness, dull, aching)
Heart, blood vessels, esophagus and
visceral pleura are innervated by visceral
fibers
5. Parietal Pain
Parietal pain, in contrast to
visceral pain, is described as
sharp and can be localized to the
dermatome superficial to the site
of the painful stimulus.
6. Initial Approach
ABC’s first, always (look for
conditions requiring immediate
intervention)
Aspirin for potential ACS
EKG
Cardiac and vital sign monitoring
8. History
Change in pain pattern
Associated symptoms: DOE,
SOB, diaphoresis, vomiting, heart
burn, food intolerance
PHx
Social history
FHx
9. Physical Exam
General Appearance and Vitals (sick vs
not sick)
Chest exam
-Inspection (scars, heaves, tachypnea,
work of breathing)
-Auscultation (murmurs, rubs, gallops,
breath sounds)
-Percussion (dullness)
12. Life Threatening Causes of
Chest Pain
Acute Coronary Syndromes
Pulmonary Embolus
Tension Pneumothorax
Aortic Dissection
13. Acute Coronary Syndromes -
Epidemiology
In a typical ED population of
adults over the age of 30
presenting with visceral-type
chest pain, about 15 percent will
have AMI and 25 to 30 percent
will have UA
14. Acute Coronary Syndromes - History
“Typical” Chest Pain Story
(Pressure-like, squeezing,
crushing pain, worse with
exertion, SOB, diaphoresis,
radiates to arm or jaw) The
majority of patients with ACS DO
15. Acute Coronary Syndromes – EKG
Findings
STEMI - ST segment elevation
(>1 mm) in contiguous leads;
new LBBB
T wave inversion or ST segment
depression in contiguous leads
suggests subendocardial
16.
17.
18. Marker Initial
Rise
Peak Return to
normal
Benefits
Troponin 2-4 hr 10 -24 hr 5 -10 days Sensitive and specific
CK-MB 3-4 hr 10-24 hr 2 – 4 days Unaffected by renal failure
LDH 10 hr 24 -72 hr 14 days
Myoglobin 1-2 hr 4 -8 hr 24 hours Very sensitive, powerful
negative predictive value
Acute Coronary Syndromes – Cardiac Markers
20. Echocardiogram
Wall abnormalities occur within
minutes
Will detect abnormalities in 80%
of AMI
Normal resting echo in setting of
chest pain gives low probability
Early screen for AMI
26. Acute Coronary Syndromes -
Disposition
Mortality is twice as high for
missed MI
Missed MI is the most
successfully litigated claim
against EP's. EP’s miss 3-5%
27. Acute Coronary Syndromes -
Disposition
A single set of cardiac enzymes
is rarely of use
Risk Stratification: goal is to
predict the likelihood of an
adverse cardiovascular event
Combination of H+P, EKG,
29. Pulmonary Embolism – History
Dyspnea is the most common
symptom, present in 90% of
patients diagnosed with PE
Sharp pleuritic chest pain,
syncope,
Prolonged immobilization,
31. Pulmonary Embolism –
Diagnostic Testing
Sinus Tachycardia is the most
frequent EKG finding
Classic S1,Q3,T3 finding is seen
in less than 20%
ABG plays no role in ruling out
32. Pulmonary Embolism – Wells Criteria
Clinical Signs and Symptoms of DVT? Yes +3
PE is #1 Diagnosis, or Equally Likely? Yes +3
Heart Rate > 100? Yes +1.5
Immobilization at least 3 days, or Surgery in the
Previous 4 weeks? Yes +1.5
Previous, objectively diagnosed PE or
DVT? Yes +1.5
Hemoptysis? Yes +1
Malignancy w/ Treatment within 6 mo, or
42. Aortic Dissection - Diagnosis
Tearing chest pain radiating to the
back
Risk Factors: HTN, connective tissue
disease
Exam: HTN, pulse differentials, neuro
deficits
43.
44. Aortic Dissection - Classification
De Bakey system: Type I dissection
involves both the ascending and
descending thoracic aorta. Type II
dissection is confined to the ascending
aorta. Type III dissection is confined to
the descending aorta.
The Daily system classifies dissections
45.
46. Aortic Dissection - Treatment
Patients with uncomplicated aortic dissections
confined to the descending thoracic aorta (Daily
type B or De Bakey type III) are best treated with
medical therapy.
Medical Therapy: Goal to decrease the blood
pressure and the velocity of left ventricular
contraction, both of which will decrease aortic
shear stress and minimize the tendency to further
dissection.
Acute ascending aortic dissections (Daily type A or
