Picture the scene…
It’s nearing midnight on the Majors side of the ED and almost time for your shift to end when a consultant approaches you and asks, “could you just see one more before you finish. Go on, it’s a chest pain, it’ll be quick”…
To learn about the management of the patient with chest pain in the Emergency Department.
Task 1 – Read
Read this blog post from RCEM Learning. Note that often the ED approach is “rule out the worst case scenario”, rather than “make a diagnosis”. In patients with chest pain those diagnoses we want to rule out are: ACS/myocardial infarction; aortic dissection; Pulmonary Embolus and Pneumothorax1.
Task 3 – Discuss
This part of the teaching session should be lead by an experienced clinician. The cases provided are merely examples and if possible the learners should be encouraged to discuss patients they have seen in their clinical practice.
Case 1 – A patient with chest pain
A 60 year old man presents to ED triage with sudden onset chest pain going through to his back. He describes it as “tearing” in nature. He has no past medical history, is not on any medication apart from antihypertensives (which he doesn’t like taking!) and his examination is normal (apart from a blood pressure of 180/100 – which he tells you always happens when he is in hospital.
1, Whereabouts in the Emergency Department do you think he should be cared for and why?
This patient should be moved to the Resuscitation Room. Although he seems relatively well, he pain is very concerning for aortic dissection and he needs regular monitoring and close observation.
2, What would you do next?
Firstly inform a senior! This patient is potentially very unwell and may have a life threatening diagnosis.
3, What investigations would you request?
Your senior will give you advice about what to do next, but it will likely involve an echocardiogram (especially if the patient becomes hypotensive) and/or a CT aortogram. The echo can show a dissection falp and cruically look for a pericardial effusion (+/- tamponade). Although aortic dissection is a rare diagnosis it isn’t one we can miss as it can be life threatening. If the diagnosis is even contemplated you need to do investigations that will rule it out as much as possible.
Case 2 – A patient with chest pain
A 35 year old woman presents with an intermittant history of pleuritic chest pain. She feels short of breath on exertion and her oxygen saturations are 95% on air.
1, What other questions would you ask in the first few minutes of your clinical assessment?
The key diagnosis to rule out here is pulmonary embolism. Although rare in the under 40s there are not many other serious reasons for chest pain in this patient. Risk factors for PE should be asked, including family history, history of travel; immobilisation (due to hospitalization, recovery from injury, bedrest, or paralysis); pregnancy; certain medications or a history of thrombophilia. Clinical signs in additon to (pleuritic) chest pain include haemoptysis and shortness of breath.
2, What investigations would you perform first in this patient?
It would be reasonable to start with some form of validated risk assessment tool like the PERC score or the Well’s score. If indicated a d-dimer could be used in addition – it is a good test to say a patient doesn’t have a PE (sensitive), but if positive does not necesssarily mean the patient does have one (not specific)
A chest xray may be performed, but usually this will be to look for other causes of chest pain, such as a pneumothorax.
If suspicion remains after these tests have been completed then a CT Pulmonary Angiogram is the test of choice (CTPA).
Task 4 – Summary
In this session we have learned about the clinical assessment of the patient with chest pain
Consider these questions based on your learning today
1, What are the “Top Five” cause of chest pain that we need to rule out in the Emergency Department?
The five top life threatening causes of chest pain that we must rule out are: ACS/MI; pulmonary embolus; aortic dissection; pneumothorax and pneumonia.
2, What tests may be useful in the rule out of life threatening causes of chest pain in the ED?
First and foremost a thorough clinical history and examination are the best tests we have to narrow the differential diagnosis.
a, An ECG should be done on the arrival of the patient and carefully assessed for signs of ischaemia or infarction
b, Blood tests that may be useful to rule out life threatening causes of chest pain are a high sensitivity troponin (if the ECG is normal) and a d-dimer (if the pre test probability is appropriately low).
c, An echocardiogram can be helpful in the diagnosis of PE (right heart strain), aortic dissection (intimal flap and pericardial effusion) and ACS/MI (regional wall motion abnormality). A bedside ultrasound can also be used to diagnose pneumothorax.
Task 5 – Reflect
In order to embed today’s learning further, reflect on what you have learnt and record in your portfolio whether it has had any impact (or is expected to have any impact) on your performance and practice.
Was this a topic that you were confident you knew already? Which parts were new to you? Were there elements that you will use on your next clinical shift.
Dscuss this session with your colleagues – were there people who missed it who you can share the highlights with?
- 1.Connolly C. Induction – Chest Pain – RCEM Learning. RCEM Learning. Published February 18, 2018. Accessed June 6, 2020. https://www.rcemlearning.co.uk/foamed/induction-chest-pain/
Lesson Plan prepared by Iain Beardsell, Consultant in Emergency Medicine, University Hospital Southampton